Reversal of Severe Heart Failure With a Continuous-Flow Left Ventricular Assist Device and Pharmacological Therapy A Prospective Study
Reversal of Severe Heart Failure With a Continuous-Flow Left Ventricular Assist Device and Pharmacological Therapy A Prospective Study
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DOI：
10.1161/circulationaha.109.933960
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发表时间：
2011-02-01
期刊：
影响因子：
37.8
通讯作者：
Khaghani, Asghar
中科院分区：
文献类型：
--
作者：
Birks, Emma J.;George, Robert S.;Khaghani, Asghar
背景-我们以前已经证明，药物治疗和左心室辅助装置卸载的特定组合导致三分之二接受Heartmate I脉动装置的扩张型心肌病患者的显著心肌恢复，足以允许泵移除。然而，这个协议还没有被用于nonpulsatile devices.Methods and Results-We报告的结果的前瞻性研究的20例患者谁收到了组合的血管紧张素转换酶，β-受体阻滞剂，血管紧张素II抑制剂，和醛固酮拮抗剂，其次是β（2）-激动剂克仑特罗和定期测试（超声心动图，运动试验，导管插入术）与泵在低速。在左心室辅助装置插入前，患者年龄为35.2 ± 12.6岁（16例男性患者），患者使用2.0 ± 0.9正性肌力药物，7例（35%）使用主动脉内球囊反搏，2例接受血液滤过，2例接受通气，3例既往使用Levitronix装置，1例接受体外膜肺氧合。心脏指数为1.39+/-0.43 L。min（-1）。m（-2），肺毛细血管楔压为31.5 ± 5.7 mm Hg，心力衰竭病史为3.4 ± 3.5年。1例患者失访，在支持240天后死亡。在其余19例患者中，12例（63.2%）在286+/-97天后恢复。8人出现症状性心力衰竭6个月（48至132个月）。除颤前，低流量15分钟，射血分数为70+/-7%，左心室舒张末期内径为48.6+/-5.7 mm，左心室收缩末期内径为32.3+/-5.7 mm，dotO（2）上的m（V）为21.6+/-4 mL。kg（-1）。min（-1），肺毛细血管楔压为5.9 ± 4.6 mm Hg，心脏指数为3.6 ± 0.6 L。min（-1）。m（-2）。1年和3年时无心力衰竭复发的估计生存率为83.3%。经过430.7+/-337.1天的随访，存活的移植物的射血分数为58.1+/-13.8%，左心室舒张末期直径为59.0+/-9.3 mm，左心室收缩末期直径为42.0+/-10.7 mm，m（V）超过dotO（2）为22.6+/-5.3 mL。kg（-1）。结论：通过联合应用机械和药物治疗，可使相当大比例的非搏动性血流患者恢复非缺血性心肌病继发的终末期心力衰竭。（循环。2011;123：381-390.）
Background-We have previously shown that a specific combination of drug therapy and left ventricular assist device unloading results in significant myocardial recovery, sufficient to allow pump removal, in two thirds of patients with dilated cardiomyopathy receiving a Heartmate I pulsatile device. However, this protocol has not been used with nonpulsatile devices.Methods and Results-We report the results of a prospective study of 20 patients who received a combination of angiotensin-converting enzymes, beta-blockers, angiotensin II inhibitors, and aldosterone antagonists followed by the beta(2)-agonist clenbuterol and were regularly tested (echocardiograms, exercise tests, catheterizations) with the pump at low speed. Before left ventricular assist device insertion, patient age was 35.2+/-12.6 years (16 male patients), patients were on 2.0+/-0.9 inotropes, 7 (35%) had an intra-aortic balloon pump, 2 were hemofiltered, 2 were ventilated, 3 had a prior Levitronix device, and 1 had extracorporeal membrane oxygenation. Cardiac index was 1.39+/-0.43 L . min(-1) . m(-2), pulmonary capillary wedge pressure was 31.5+/-5.7 mm Hg, and heart failure history was 3.4+/-3.5 years. One patient was lost to follow-up and died after 240 days of support. Of the remaining 19 patients, 12 (63.2%) were explanted after 286+/-97 days. Eight had symptomatic heart failure for 6 months (48 to 132 months). Before explantation, at low flow for 15 minutes, ejection fraction was 70+/-7%, left ventricular end-diastolic diameter was 48.6+/-5.7 mm, left ventricular end-systolic diameter was 32.3+/-5.7 mm, m(V) over dotO(2) was 21.6+/-4 mL . kg(-1) . min(-1), pulmonary capillary wedge pressure was 5.9+/-4.6 mm Hg, and cardiac index was 3.6+/-0.6 L . min(-1) . m(-2). Estimated survival without heart failure recurrence was 83.3% at 1 and 3 years. After a 430.7+/-337.1-day follow-up, surviving explants had an ejection fraction of 58.1+/-13.8%, left ventricular end-diastolic diameter of 59.0+/-9.3 mm, left ventricular end-systolic diameter of 42.0+/-10.7 mm, and m(V) over dotO(2) of 22.6+/-5.3 mL . kg(-1) . min(-1).Conclusions-Reversal of end-stage heart failure secondary to nonischemic cardiomyopathy can be achieved in a substantial proportion of patients with nonpulsatile flow through the use of a combination of mechanical and pharmacological therapy. (Circulation. 2011;123:381-390.)