Ventricular Arrhythmias After Left Ventricular Assist Device
Ventricular Arrhythmias After Left Ventricular Assist Device
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DOI：
10.1161/circep.113.000113
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发表时间：
2013-06-01
影响因子：
8.4
通讯作者：
Stecker, Eric C.
中科院分区：
文献类型：
--
作者：
Nakahara, Shashima;Chien, Christopher;Stecker, Eric C.
LVAD植入后报告的室性心律失常（VA）的患病率因患者人群（例如，心肌病的原因、LVAD的适应症、LVAD的类型）、心律失常的定义、监测方法和随访时间而异。然而，VA是LVAD植入后常见的不良事件，特别是在前30天。在移植桥试验中，在中位126天随访期间，24%接受HeartMate II的患者发生需要心脏复律或除颤的VA。6在单中心观察性研究中也观察到了类似的结果，据报道VA发生在22%至59%的LVAD接受者中（表）。6、10-18在LVAD植入前未发生VA的患者中也可观察到偶发VA。Ziv等人14回顾性研究了91例接受第一代Heartmate XVE器械植入的连续患者。在他们的队列中，63%的患者患有缺血性心肌病，42%的患者在LVAD前使用胺碘酮。VA定义为通过ICD询问、遥测或ECG检测到的室性心动过速（VT）或室颤（VF），持续时间≥ 30 s或需要除颤或抗心动过速起搏。共有32例患者（35%）在LVAD植入后出现VA。18例LVAD植入前无室性心动过速的患者在LVAD植入后新发单形性室性心动过速。10例患者在LVAD植入后也发生了新发多形性VT或VF。VA最常见于术后早期。在HeartMate II桥接移植研究中，LVAD植入后前30天VA（年化发生率为2.55/患者-年）比随访> 30天（年化发生率为0.45/患者-年）更常见。6这支持了Ziv等人14的观察结果，即在第一代LVAD植入后发生VA的32例患者中，有31例在手术后2周内首次发作。Andersen等人17指出，12例持续性VT或VF患者中有9例（75%）在LVAD置入后4周内发生心律失常。其他研究者也报告了类似的结果，VA经常发生在术后早期，并在较长时间内下降。16，19术后早期和晚期VA的机制尚未阐明，但围手术期肾上腺素能刺激和肾上腺素能激动剂的使用可能在促进早期心律失常中发挥重要作用，而LVAD支持下的积极心脏重塑可能在随访后期VA降低中起重要作用。同样重要的是要注意，尽管大多数心律失常发生在早期，但有限的数据表明，四分之一到三分之一的患者可能在30天后首次出现VA。6，18基线因素和LVAD类型均可预测VA的风险。在2项多变量分析中，LVAD植入前的VA既往史与LVAD植入后心律失常的发生率相关。18，20多项研究还表明，心肌病的缺血性发病机制是LVAD置入后VA的诱发因素。13，14，16，21植入辅助装置的类型也可以预测VA的风险。在一项对124例LVAD患者和71例bi-VAD患者的回顾性研究中，在调整多个变量后，LVAD接受者发生任何类型心律失常的风险比bi-VAD接受者显著增加2倍。19此外，几项研究表明，与脉动泵相比，连续流泵中VA的发生率增加。10，12，17在摘要中报告的一项研究中，将连续流HeartMate II与脉动流HeartMate XVE进行比较，10心率增加了2倍..
The reported prevalence of ventricular arrhythmia (VA) after LVAD implantation varies on the basis of patient population (eg, causes of cardiomyopathy, indication for LVAD, type of LVAD), definition of the arrhythmia, method of surveillance, and time of follow-up. However, VAs are common adverse events after LVAD implantation, particularly in the first 30 days. VAs requiring cardioversion or defibrillation occurred in 24% of patients who received a HeartMate II during a median 126-day follow-up period in a bridge to transplant trial. 6 Similar findings have been seen in single-center observational studies, where VA have been reported to occur in 22% to 59% of LVAD recipients (Table). 6, 10–18 Incident VAs are also seen in patients who have not had VA before LVAD implant. Ziv et al14 retrospectively studied 91 consecutive patients who underwent implant of a firstgeneration Heartmate XVE device. Sixty-three percent of the patients in their cohort had ischemic cardiomyopathy and 42% used amiodarone before LVAD. VAs were defined as ventricular tachycardia (VT) or ventricular fibrillation (VF) detected by ICD interrogation, telemetry, or ECG and lasting≥ 30 s or requiring defibrillation or antitachycardia pacing. A total of 32 patients (35%) had VA after LVAD implant. Eighteen patients who had no VT before LVAD implant had de novo monomorphic VT after LVAD implant. Ten patients had de novo polymorphic VT or VF after LVAD implant as well. VAs are most common in the early postoperative period. In the HeartMate II bridge to transplant study, VA were much more common in the first 30 days after LVAD implant (annualized rate of 2.55 per patient-year) than in follow-up> 30 days (annualized rate of 0.45 per patient-year). 6 This supported observations by Ziv et al14 that 31 of 32 patients who had VA after first-generation LVAD implant had their first episode within 2 weeks of surgery. Andersen et al17 noted 9 of 12 patients (75%) who had sustained VT or VF experienced the arrhythmias within 4 weeks of LVAD placement. Other investigators have also reported similar findings, with VA occurring frequently during the early postoperative period and decreasing over the longer term. 16, 19 Mechanisms of VA in early and late postoperative periods have not been elucidated, but it is likely that perioperative adrenergic stimulation and the use of adrenergic agonists may play an important role in promoting early arrhythmias, whereas positive cardiac remodeling on LVAD support may be important in decreased VA later during followup. It is also important to note that although the majority of arrhythmias occur early, limited data suggest that a quarter to a third of patients may experience their first VA after 30 days. 6, 18 Both baseline factors and type of LVAD predict risk for VA. In 2 multivariable analyses, a previous history of VA before LVAD placement was associated with incidence of arrhythmias after LVAD implant. 18, 20 Several studies have also shown that ischemic pathogenesis of cardiomyopathy is a predisposing factor for VA after LVAD placement. 13, 14, 16, 21 The type of implanted assist device can also predict risk of VA. In a retrospective study of 124 patients with LVAD and 71 patients with bi-VAD, there was a significant 2-fold increase in risk for developing any type of arrhythmia in LVAD recipients versus bi-VAD recipients after adjusting for multiple variables. 19 In addition, several studies have shown an increased incidence of VA in continuous flow pumps compared with pulsatile pumps. 10, 12, 17 In a study reported in abstract, comparing the continuous flow HeartMate II with the pulsatile flow HeartMate XVE, 10 there was a 2-fold increase in rate …