Right heart failure and "failure to thrive" after left ventricular assist device: Clinical predictors and outcomes
Right heart failure and "failure to thrive" after left ventricular assist device: Clinical predictors and outcomes
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DOI：
10.1016/j.healun.2011.03.006
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发表时间：
2011-08-01
影响因子：
8.9
通讯作者：
Hayward, Christopher S.
中科院分区：
文献类型：
--
作者：
Baumwol, Jay;Macdonald, Peter S.;Hayward, Christopher S.
背景：本研究确定了术后早期右心衰竭 (RHF) 及其后果的预测因素，以及插入连续流左心室辅助装置 (LVAD) 后临床长期健康发展的预测因素。 方法：对 40 名接受第三代离心流左心室辅助装置的连续患者的术前和最新随访数据进行分析。 RHF 的定义使用先前描述的标准，包括术后正性肌力药物、肺血管扩张剂的使用或右侧机械支持。还根据 LVAD 插入后的临床结果对患者进行分类。结果：33 名患者植入 LVAD 作为移植桥梁 (BIT)，7 名患者植入 LVAD 作为目标治疗。在 LVAD 植入之前，22 名患者的机械辅助循环支持机构间登记 (INTERMACS) 级别为 1 级，17 名患者为 2 级。在 LVAD 植入时，50% 的患者接受了临时机械辅助。 6 个月生存率/移植进展率为 92.5%。平均 LVAD 支持时间为 385 天（范围：21-1,011 天）。 40 名患者中有 13 名术后发生 RHF（32.5%）。 RHF 患者比非 RHF 患者术前三尖瓣关闭不全更严重。有 RHF 证据的 BTT 患者的移植生存率（11 例中的 6 例 [54.5%]）比没有 RHF 的患者（22 例中的 20 例 [90.9%]）较差，p = 0.027）。短期 RHF 没有其他血流动力学或超声心动图预测因素。 LVAD 后，40 名患者中有 22 名 (55%) 临床状况良好。对于 BTT 患者，21 名茁壮成长的患者中，有 20 名 (95%) 进展到移植或在最近一次随访时存活，而 12 名未能茁壮成长的患者中，有 6 名 (50%) (FIT；p < 0.005)。与 FTT 患者相比，茁壮成长者的纽约心脏协会分级较低（1.5 vs 2.9，p < 0.001），住院时间较少，室性心动过速也较少。然而，术前 INTERMACS 水平、超声心动图、血流动力学和生化指标或术后早期 RHF 没有发现差异。年龄是唯一显着的预测因素：茁壮成长者明显年轻（43.7 +/- 15.9 vs 60.3 +/- 12.6 岁；p < 0.001）。在排除目的地策略患者后，这种年龄差异没有变化。患者的右心室功能恶化，而健康的患者则保持稳定。结论：术后早期 RHF 导致 BTT 患者的生存率/移植进展较差，并且可以通过术前更大的三尖瓣功能不全来预测。对于那些在 LVAD 插入后临床上能长期健康成长的人来说，最重要的预测因素是年轻化。 J Heart Lung Transplant 2011；30:888-95 Crown 版权所有 (C) 2011 由 Elsevier Inc. 出版。保留所有权利。
BACKGROUND: This study determined predictors of early post-operative right heart failure (RHF) and its consequences, as well as predictors of those who clinically thrive longer term after insertion of a continuous-flow left ventricular assist device (LVAD).METHODS: Pre-operative and latest follow-up data were analyzed for 40 consecutive patients who received third-generation centrifugal-flow LVADs. RHF was defined using previously described criteria, including post-operative inotropes, pulmonary vasodilator use, or right-sided mechanical support. Patients were also categorized according to clinical outcomes after LVAD insertion.RESULTS: LVADs were implanted as a bridge to transplantation (BIT) in 33 patients and as destination therapy in 7. Before LVAD implant, 22 patients were Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 1, and 17 were at level 2. Temporary mechanical assistance was present in 50% of the cohort at LVAD implantation. The 6-month survival/progression to transplant was 92.5%. Average LVAD support time was 385 days (range, 21-1,011 days). RHF developed postoperatively in 13 of 40 patients (32.5%). RHF patients had more severe pre-operative tricuspid incompetence than non-RHF patients. The BTT patients with evidence of RHF had poorer survival to transplant (6 of 11 [54.5%]) than those without RHF (20 of 22 [90.9%]), p = 0.027). There were no other hemodynamic or echocardiographic predictors of short-term RHF. After LVAD, 22 of the 40 patients (55%) thrived clinically. For BTT patients, 20 of 21 (95%) of those who thrived progressed to transplant or were alive at latest follow-up vs 6 of 12 (50%) of those who failed to thrive (FIT; p < 0.005). The thrivers had lower New York Heart Association class (1.5 vs 2.9, p < 0.001), spent less time in the hospital, and had less ventricular tachycardia than the FTT patients. However, no differences were noted in pre-operative INTERMACS level, echocardiographic, hemodynamic, and biochemical indices, or in early post-operative RHF. Age was the only significant predictor: the thrivers were significantly younger (43.7 +/- 15.9 vs 60.3 +/- 12.6 years; p < 0.001). This age difference was unchanged after exclusion of destination strategy patients. RV function deteriorated in the patients and remained stable in those who thrived.CONCLUSIONS: Early post-operative RHF results in poorer survival/progression to transplantation for BTT patients and is predicted by greater pre-operative tricuspid incompetence. The most important predictor for those who will clinically thrive longer-term after LVAD insertion is younger age. J Heart Lung Transplant 2011;30:888-95 Crown Copyright (C) 2011 Published by Elsevier Inc. All rights reserved.