Does Size Matter With Continuous Left Ventricular Assist Devices?
Does Size Matter With Continuous Left Ventricular Assist Devices?
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尺寸对于连续左心室辅助装置重要吗？
DOI：
10.1016/j.jchf.2016.10.002
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发表时间：
2017
期刊：
影响因子：
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通讯作者：
Hsich,EileenM
中科院分区：
文献类型：
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作者：
Hsich,EileenM
——meghan Trainor, All About That Bass(1)多年来，体表面积(BSA)< 1.5 m2的成年患者很少有移植的选择，也没有目的地治疗的选择。心室辅助装置的发展提高了我们抢救心力衰竭患者的能力，并使我们考虑到大小无关紧要的可能性。机械循环装置的概念始于50多年前。1964年，国家心脏研究所组织了人工心脏项目，并提供了资金支持这项努力。到1967年，DeBakey(3)成功地桥接了一名“瘦弱危重”的37岁女性和一名16岁的女孩，他们在瓣膜手术后使用了临时体外气动装置，其中左心房的流入插管和右腋下动脉的流出插管。年轻女性需要机械循环支持10天，少女需要4天(3)。1978年，第一位患者通过临时左心室辅助装置进行心脏移植5天，但几周后因肠穿孔死亡(4)。到20世纪80年代，长期植入式电左心室辅助装置终于出现，并报道了20例患者（BSA范围1.67至2.19 m2）机械支持1小时至90天的经验，其中50%的患者桥接移植(5)。这一成就导致了第一代左心室辅助装置的出现。第一代设备是脉冲式的，采用容积泵。这些设备的重量范围从2.2磅（Novacor, World Heart Corporation, Ottawa, Ontario, Canada）到2.5磅（HeartMate XVE, Thoratec, Pleasanton, California），并要求接受者的BSA bbb1.5 m2（图1）。随后的几代设备是连续流泵，更轻（即< 1磅），具有轴向或离心流(6)。大多数连续流动装置适合“小个子”人群，但其安全性尚不清楚。Zafar等人(7)在这一期《JACC: Heart Failure》上的出色研究首次提供了实质性证据，证明连续血流装置相对安全，并且与BSA# 1.5 m2的患者相比，BSA# 1.5 m2的患者具有相似的生存获益。他们的研究纳入了2008年4月至2013年9月在INTERMACS（机械辅助循环支持机构间登记）中使用连续流装置的所有成年人，并排除了使用双心室辅助装置支持的患者。BSA为1.5 m2的患者多为女性（68% vs. 20%, p< 0.001），西班牙裔患者较多（10.4% vs. 6.1%, p= 0.025），与BSA为1.5 m2的患者相比，血清肌酐较低（1.2 mg/dl vs. 1.4 mg/dl, p< 0.001）， BNP较高（1703 pg/ml vs. 1151 pg/ml, p< 0.001）。连续血流装置的不良事件很少，但bsa# 1.5 m2的患者发生传动系统感染和非纵隔出血的风险更高。与BSA为1.5 m2的患者相比，他们发生肾功能不全或右心衰的风险也相对较低。
—Meghan Trainor, All About That Bass (1) For many years, adult patients with a body surface area (BSA)< 1.5 m2 had few options to bridge to transplantation and no option for destination therapy. The evolution of ventricular assist devices has improved our ability to rescue heart failure patients and has allowed us to consider the possibility that size does not matter. The conception of mechanical circulatory devices began more than 50 years ago. In 1964, the Artificial Heart Program was organized by the National Heart Institute, and funding was provided to support the endeavor (2). By 1967, DeBakey (3) had successfully bridged to recovery a “thin and critically ill” 37-yearold woman and a 16-year-old girl after valvular surgery with a temporary extracorporeal pneumatic device that had the inflow cannula in the left atrium and the outflow cannula in the right axillary artery. The young woman needed mechanical circulatory support for 10 days, and the teenage girl for 4 days (3). By 1978, the first patient was bridged to heart transplantation with a temporary left ventricular assist device for 5 days, but died a few weeks later from a perforated bowel (4). By the 1980s, long-term implantable electrical left ventricular assist devices were finally available, and the experience of 20 patients (BSA range 1.67 to 2.19 m2) who were mechanically supported for 1 h to90 days was reported, with 50% bridged to transplantation (5). This accomplishment led to the first generation of left ventricular assist devices. The first generation of devices was pulsatile, with positive displacement pumps. These devices ranged in weight from 2.2 lbs (Novacor, World Heart Corporation, Ottawa, Ontario, Canada) to 2.5 lbs (HeartMate XVE, Thoratec, Pleasanton, California) and required the recipient to have a BSA> 1.5 m2 (Figure 1). The subsequent generations of devices were continuousflow pumps that were much lighter (ie,< 1 lb) with axial or centrifugal flow (6). Most of the continuousflow devices fit in “small” people, yet their safety remains unclear.The excellent study by Zafar et al.(7) in this issue of JACC: Heart Failure provides the first substantial evidence that continuous-flow devices are relatively safe and provide similar survival benefit for patients with BSA# 1.5 m2 compared with BSA> 1.5 m2. Their study included all adults in the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) from April 2008 to September 2013 with a continuous-flow device and excluded those patients with biventricular assist device support. Patients with BSA# 1.5 m2 were mostly women (68% vs. 20%; p< 0.001), were more likely Hispanic (10.4% vs. 6.1%; p= 0.025), had lower serum creatinine (1.2 mg/dl vs. 1.4 mg/dl; p< 0.001) and higher BNP (1,703 pg/ml vs. 1,151 pg/ml, p< 0.001) compared with patients with BSA> 1.5 m2. There were few adverse events with continuous-flow devices, but patients with BSA# 1.5 m2 had a higher risk of driveline infection and nonmediastinal bleeding. They also had a relatively lower risk of renal insufficiency or right ventricular failure compared with patients with BSA> 1.5 m2.