Schmidinger H
Department of Cardiology, University of Vienna, Austria.
Am J Cardiol. 1999 Mar 11;83(5B):151D-157D. doi: 10.1016/s0002-9149(98)01017-0.
Heart transplantation is an accepted therapeutic option for patients with end-stage heart disease. However, because the availability of heart donors fails to keep pace with the growing demand, increasing numbers of potential recipients are placed on the waiting list, resulting in longer waiting times. About 20% of patients die while awaiting heart transplantation. The majority die from progressive pump failure (46%), whereas about 30% of all deaths occur suddenly. Monitored terminal cardiac electrical activity in patients dying while awaiting transplantation reveals that bradyarrhythmias and/or electromechanical dissociation are involved in 68% of cases and ventricular tachyarrhythmias in 32% of cases. Patients with a history of aborted cardiac arrest are at highest risk for recurrent malignant arrhythmias. The implantable cardioverter defibrillator (ICD) is the most effective therapy for preventing sudden cardiac death from ventricular tachyarrhythmias. Pooled data from a total of 75 sudden death survivors listed for cardiac transplantation demonstrate that ICD therapy can be applied with low mortality, low morbidity, and high efficacy, with up to 94% of the patients receiving appropriate shocks during the waiting period. However, there is considerable concern that this early survival benefit conferred by the ICD may be nullified by the competing risk of death due to terminal pump failure, as the waiting list and waiting time to transplantation lengthens. In advanced heart failure, risk stratification for sudden tachyarrhythmic death is only of limited value. Therefore, although sudden tachyarrhythmic death appears to constitute only a minor fraction of total cardiac death in patients awaiting heart transplantation, prophylactic ICD implantation as on electronic bridge to transplant may be considered. To define conclusively the role of prophylactic ICD therapy in this setting, prospective randomized studies are needed.
心脏移植是终末期心脏病患者可接受的治疗选择。然而，由于心脏供体的可获得性无法跟上不断增长的需求，越来越多的潜在受者被列入等待名单，导致等待时间延长。约20%的患者在等待心脏移植期间死亡。大多数患者死于进行性泵衰竭（46%），而所有死亡病例中约30%为猝死。对等待移植期间死亡患者的终末期心脏电活动进行监测发现，68%的病例涉及缓慢性心律失常和/或电机械分离，32%的病例涉及室性快速心律失常。有心脏骤停未遂病史的患者发生复发性恶性心律失常的风险最高。植入式心脏复律除颤器（ICD）是预防室性快速心律失常导致心源性猝死的最有效治疗方法。对总共75名等待心脏移植的心脏性猝死幸存者的汇总数据表明，ICD治疗的死亡率低、发病率低且疗效高，高达94%的患者在等待期间接受了适当的电击。然而，人们相当担心，随着等待名单和移植等待时间的延长，ICD带来的这种早期生存益处可能会被终末期泵衰竭导致的死亡这一竞争风险抵消。在晚期心力衰竭中，对室性快速性心律失常性死亡进行风险分层的价值有限。因此，尽管室性快速性心律失常性死亡似乎仅占等待心脏移植患者心脏性死亡总数的一小部分，但可考虑植入预防性ICD作为移植的电子桥梁。为了最终确定预防性ICD治疗在这种情况下的作用，需要进行前瞻性随机研究。
