Utilization of multimodal imaging for the evaluation of left ventricular remodeling and risk stratification in severe aortic regurgitation
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摘要: 主动脉瓣反流(aortic regurgitation，AR)严重程度和左心室(left ventricular，LV)重塑水平密切相关，确定AR干预时机对患者长期预后至关重要，心脏超声、心脏磁共振、CT及生物标记物等多模态影像均可用于评估AR的严重程度，但对LV重塑水平评估存在一定不足。本文指出多模态影像评估从功能参数、结构参数等角度来评价AR患者LV重塑水平，并总结其对AR临床决策制定的指导意义，为临床运用提供参考。Abstract: The severity of aortic regurgitation(AR) is closely associated with the extent of left ventricular(LV) remodeling. The timing of AR intervention plays a pivotal role in determining the long-term prognosis for patients. Various multimodal techniques, including cardiac ultrasound, cardiac magnetic resonance imaging, computed tomography, and biomarkers, can evaluate the severity of AR disease. However, there are certain limitations in assessing LV remodeling. This article emphasizes that multimodal imaging assessment enables the evaluation of LV remodeling level in AR patients from both functional and structural perspectives and summarizes its significant implications for clinical decision-making regarding AR management, thereby providing valuable insights for practical application.
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表 1 重度AR的LV不同重塑水平参数
Table 1. Parameters of different levels of LV remodeling in severe AR
项目 正常参考值 LV高水平重塑 LV中等水平重塑 LV低水平重塑 功能参数 LVEF[6] ≥55%~70% < 50% 50~55% >55% dP/dt/(mmHg/s)[26] >1 200 < 1 000 1 000~1 200 E峰/A峰比值[27] 0.8~2 ≥2 E峰/e′比值[27] < 8 >14 8~14 S峰/D峰比值[28] 1~2 >2 1-2 < 1 结构参数 LA volume index/(mL/m2)[22] 正常值因性别、体表面积而异 >49(>34) 41~49 ≤40 LVEDV/mL[18] 男性：181.2±73.6
女性：133.6±38.9< 246 246~470 >470 全局纵向应变[8] 男性：(-19.0±3.4)%
女性：(-12.2±2.6)%>-19% -22%~-19% ≤-22% LVEF：左室射血分数；dP/dt：左室压力上升最大速率；E峰/A峰比值：二尖瓣舒张早期血流速度(E峰)和舒张晚期血流速度(A峰)的比值；E峰/e′比值：二尖瓣舒张早期血流速度(E峰)和二尖瓣环组织多普勒早期舒张速度(e′)的比值；S峰/D峰比值：肺静脉血流的收缩期(S峰)和舒张期(D峰)速度比值；LA volume index：左心房容积指数；LVESV：左心室收缩末期容积；LVEDV：左心室舒张末期容积。 
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表 2 重度AR风险分类及分层
Table 2. Classification and stratification of severe AR
危险分层 分类标准 关键指标 处理建议 高风险 有症状的重度反流 存在临床症状(呼吸困难、胸痛等)
多模态成像确认重度反流TAVI或外科手术 中风险 无症状但存在以下任一情况：
①LVEF≤50%
②60%>LVEF>50%需评估LV重塑水平
③左心室扩张LVEF≤50%或动态下降至50%~60%
LVESD>50 mm(或>25 mm/m2)
LVEDD>70 mm(或进行性增长>65 mm)定期监测
结合LV重塑评估决定是否手术低风险 无症状且左心室功能/结构正常 LVEF>60%
LVESD≤50 mm(或≤25 mm/m2)
LVEDD≤65 mm保守治疗(每6~12个月随访) 注：LV重塑水平评估内容：功能指标：二尖瓣环应变、E/e′比值、缩短速度、dP/dt、收缩期充盈压力。结构指标：LVESV、LVEDV、室壁应力、CS/LS、心肌纤维化(心脏MRI)。异常提示：若出现心肌应变异常、心室容积增大或纤维化，需升级至高风险并干预。TAVI：经导管主动脉瓣置换术。
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