Pasquet A, Lauer M S, Williams M J, Secknus M A, Lytle B, Marwick T H
Cleveland Clinic Foundation, Cleveland, OH, USA.
Eur Heart J. 2000 Jan;21(2):125-36. doi: 10.1053/euhj.1999.1663.
Previous studies have compared the accuracy of various tests of viability for the prediction of recovery of regional left ventricular function; global left ventricular recovery has been less well studied, although it has important prognostic and functional ramifications. We sought to identify the relative contribution of ischaemia, regional and global contractile reserve, perfusion and metabolic function to changes in left ventricular volumes and global function after coronary artery bypass surgery in patients with severe left ventricular dysfunction.
Dipyridamole stress Rb-82, fluorodeoxyglucose positron emission tomography and low and high-dose dobutamine-atropine stress echocardiography were obtained in 66 patients with left ventricular impairment. Myocardial segments were considered viable if ischaemia or either metabolic or contractile reserve were present, on positron emission tomography or dobutamine echocardiography. Resting left ventricular function was reassessed after surgery (mean 10+/-3 weeks) in the 59 patients who had not suffered a major peri-operative event; functional improvement was defined by a 5% increment of ejection fraction. Myocardial viability was found in 37 (63%) patients using positron emission tomography and in 42 (71%) patients using dobutamine echocardiography; post-operative functional improvement was noted in 28 (47%) patients. In univariate analyses, predictors of global post-operative functional recovery included: the extent of viability according to positron emission tomography [OR (odds ratio): 2.08 for each additional viable segment, 95% CI (confidence interval): 1.33-3. 25, P=0.001] or dobutamine echocardiography (OR: 2.06 for each additional viable segment, 95% CI: 1.28-3.30, P=0.003) and the increase in ejection fraction with low-dose dobutamine (OR: 1.9 for each 1% increase in ejection fraction with low dose dobutamine, 95% CI 1.39-2.61, P<0.0001). In a multivariate model which included evidence of viability by either technique, and change in ejection fraction with low-dose dobutamine echocardiography, only change in ejection fraction with low-dose dobutamine echocardiography was predictive of post-operative left ventricular functional recovery (adjusted OR: 1.81, 95% CI: 1.30-2.52, P=0.0005).
Among patients with severe left ventricular dysfunction who are referred for surgical revascularization, the overall accuracies of positron emission tomography and dobutamine echocardiography for the prediction of post-operative myocardial recovery are comparable. However, the strongest predictor of overall improvement of post-operative left ventricular function is an increase of ejection fraction with a low-dose dobutamine infusion.
以往研究比较了各种存活能力测试对预测局部左心室功能恢复的准确性；尽管整体左心室恢复具有重要的预后和功能影响，但对其研究较少。我们试图确定缺血、局部和整体收缩储备、灌注及代谢功能对严重左心室功能不全患者冠状动脉搭桥术后左心室容积和整体功能变化的相对贡献。
对66例左心室功能受损患者进行双嘧达莫负荷铷-82、氟脱氧葡萄糖正电子发射断层扫描以及低剂量和高剂量多巴酚丁胺-阿托品负荷超声心动图检查。根据正电子发射断层扫描或多巴酚丁胺超声心动图检查结果，若存在缺血或代谢或收缩储备，则认为心肌节段存活。对59例未发生重大围手术期事件的患者在术后（平均10±3周）重新评估静息左心室功能；功能改善定义为射血分数增加5%。采用正电子发射断层扫描发现37例（63%）患者存在心肌存活，采用多巴酚丁胺超声心动图发现42例（71%）患者存在心肌存活；28例（47%）患者术后功能改善。在单因素分析中，术后整体功能恢复的预测因素包括：根据正电子发射断层扫描（比值比：每增加一个存活节段为2.08，95%可信区间：1.33 - 3.25，P = 0.001）或多巴酚丁胺超声心动图（比值比：每增加一个存活节段为2.06，95%可信区间：1.28 - 3.30，P = 0.003）评估的存活范围，以及低剂量多巴酚丁胺使射血分数增加的情况（比值比：低剂量多巴酚丁胺使射血分数每增加1%为1.9，95%可信区间1.39 - 2.61，P < 0.0001）。在一个多因素模型中，该模型纳入了两种技术显示的存活证据以及低剂量多巴酚丁胺超声心动图检查时射血分数的变化，只有低剂量多巴酚丁胺超声心动图检查时射血分数的变化可预测术后左心室功能恢复（校正比值比：1.81，95%可信区间：1.30 - 2.52，P = 0.0005）。
在因手术血运重建而就诊的严重左心室功能不全患者中，正电子发射断层扫描和多巴酚丁胺超声心动图预测术后心肌恢复的总体准确性相当。然而，术后左心室功能总体改善的最强预测因素是低剂量多巴酚丁胺输注时射血分数的增加。
