Meluzin Jaroslav, Spinarová Lenka, Hude Petr, Krejcí Jan, Dusek Ladislav, Vítovec Jirí, Panovsky Roman
St. Anna Hospital, Masaryk University, First Department of Internal Medicine/Cardioangiology, Brno, Czech Republic. jaroslav.fnusa.cz
Int J Cardiol. 2005 Nov 2;105(2):164-73. doi: 10.1016/j.ijcard.2004.12.031.
The presence of right ventricular systolic dysfunction is known to significantly worsen prognosis of patients with heart failure. However, the prognostic impact of right ventricular diastolic dysfunction and of its combination with right ventricular systolic dysfunction and with other prognostic markers has not yet been systematically studied. The aim of this study was to assess the prognostic impact of combined right ventricular systolic and diastolic dysfunction in patients with symptomatic heart failure due to ischemic or idiopathic dilated cardiomyopathy.
The study included 177 consecutive patients with symptomatic heart failure (mean left ventricular ejection fraction of 23%). All patients underwent clinical and laboratory examination, standard echocardiography completed by Doppler tissue imaging of the tricuspid annular motion, and right-sided heart catheterization. They were followed up for a mean period of 16 months (range, 1-48 months).
During the follow-up, there were 28 cardiac-related deaths and 35 non-fatal cardiac events (31 hospitalizations for heart failure decompensation and 4 hospitalizations for malignant arrhythmias requiring the implantation of a cardioverter-defibrillator). The multivariate stepwise Cox regression modeling revealed the right ventricular systolic (represented by the peak systolic tricuspid annular velocity-Sa) and diastolic (represented by the peak early diastolic tricuspid annular velocity-Ea) function to be the independent predictors of event-free survival or survival (p<0.01). The Sa separated better between patients with and without the risk of cardiac events (p<0.05), while the Ea appeared to further distinguish patients with increased risk (those at risk of late event from those at risk of early non-fatal event and early death). The strongest predictive information was obtained by the combination of Sa and Ea creating the Sa/Ea categories. The Sa/Ea I category of patients (Sa>or=10.8 cm s(-1) and Ea>or=8.9 cm s(-1)) had excellent prognosis. On the other hand, the Sa/Ea IV category (Sa<10.8 cm s(-1) and Ea<8.9 cm s(-1)) was found to be at a very high risk of cardiac events (p<0.001 vs. Sa/Ea I). Imbalanced categories of patients (Sa/Ea II and III) with only one component (Sa or Ea) pathologically decreased were at medium risk when assessing event-free survival. However, a significantly better survival (p<0.05) was found in patients with Ea>or=8.9 cm s(-1) (Sa/Ea I and III categories) as compared with those having Ea<8.9 cm s(-1) (Sa/Ea II and IV categories). Thus, in contrast to event-free survival, the survival pattern was determined mainly by the Ea value with only little additional contribution of Sa.
The assessment of right ventricular systolic and diastolic function provides complementary information with a very high power to stratify prognosis of patients with heart failure. The combination of right ventricular systolic and diastolic dysfunction identifies those with a very poor prognosis.
已知右心室收缩功能障碍的存在会显著恶化心力衰竭患者的预后。然而，右心室舒张功能障碍及其与右心室收缩功能障碍以及其他预后标志物联合的预后影响尚未得到系统研究。本研究的目的是评估合并右心室收缩和舒张功能障碍对因缺血性或特发性扩张型心肌病导致的症状性心力衰竭患者的预后影响。
本研究纳入了177例连续性症状性心力衰竭患者（左心室平均射血分数为23%）。所有患者均接受了临床和实验室检查、通过三尖瓣环运动的多普勒组织成像完成的标准超声心动图检查以及右心导管检查。他们平均随访了16个月（范围为1 - 48个月）。
在随访期间，有28例心脏相关死亡和35例非致命性心脏事件（31例因心力衰竭失代偿住院，4例因需要植入心脏复律除颤器的恶性心律失常住院）。多变量逐步Cox回归模型显示右心室收缩功能（以三尖瓣环收缩期峰值速度 - Sa表示）和舒张功能（以三尖瓣环舒张早期峰值速度 - Ea表示）是无事件生存或生存的独立预测因素（p<0.01）。Sa在有和无心脏事件风险的患者之间区分得更好（p<0.05），而Ea似乎能进一步区分风险增加的患者（有晚期事件风险的患者与有早期非致命事件和早期死亡风险的患者）。通过将Sa和Ea组合创建Sa/Ea类别可获得最强的预测信息。Sa/Ea I类患者（Sa≥10.8 cm s⁻¹且Ea≥8.9 cm s⁻¹）预后良好。另一方面，发现Sa/Ea IV类（Sa<10.8 cm s⁻¹且Ea<8.9 cm s⁻¹）发生心脏事件的风险非常高（与Sa/Ea I类相比，p<0.001）。在评估无事件生存时，仅一个成分（Sa或Ea）病理降低的不平衡类别患者（Sa/Ea II和III）处于中等风险。然而，与Ea<8.9 cm s⁻¹（Sa/Ea II和IV类）的患者相比，Ea≥8.9 cm s⁻¹（Sa/Ea I和III类）的患者生存情况明显更好（p<0.05）。因此，与无事件生存不同，生存模式主要由Ea值决定，Sa的额外贡献很小。
右心室收缩和舒张功能的评估提供了互补信息，对心力衰竭患者的预后分层具有很高的预测能力。右心室收缩和舒张功能障碍的联合可识别出预后非常差的患者。
