晚期充血性心力衰竭的外科心室修复：肺动脉高压应成为禁忌证吗？

Surgical ventricular restoration for advanced congestive heart failure: should pulmonary hypertension be a contraindication?

作者信息

Patel Nishant D, Williams Jason A, Nwakanma Lois U, Waldron Michele M, Bluemke David A, Conte John V

机构信息

Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.

出版信息

Ann Thorac Surg. 2006 Sep;82(3):879-88; discussion 888. doi: 10.1016/j.athoracsur.2006.04.016.

DOI:10.1016/j.athoracsur.2006.04.016

PMID:16928501

Abstract

BACKGROUND

Surgical ventricular restoration (SVR) is an established therapy for congestive heart failure due to ischemic cardiomyopathy. Pulmonary hypertension (PHTN) has been considered a contraindication for SVR owing to a presumed increase in operative risk. However, outcomes in these patients and the impact of SVR on PHTN have not been specifically evaluated.

METHODS

We retrospectively reviewed SVR patients between January 2002 and June 2005. Patients were classified as PHTN (mean pulmonary artery pressure > or = 25 mm Hg) and no PHTN (mPAP < 25 mm Hg) based on preoperative cardiac catheterization. Cardiac function was assessed using magnetic resonance imaging and echocardiography. Follow-up was 100%.

RESULTS

Sixty-nine patients underwent SVR for congestive heart failure. Thirty-six percent (25 of 69) had preoperative PHTN. Preoperatively, PHTN patients had significantly lower ejection fraction (21.1% versus 30.0%; p = 0.005) and larger left ventricular end-systolic volume index (119.0 versus 88.7 mL/m2; p = 0.04) than patients without PHTN. All PHTN patients and 95.5% (42 of 44) of the no PHTN group were New York Heart Association (NYHA) class III/IV preoperatively. There was 1 operative death in the PHTN group. Surgical ventricular restoration significantly improved cardiac function and pulmonary pressures for PHTN patients. Both groups had similar cardiac function postoperatively. Seventy-two percent (18 of 25) of PHTN patients and 69.0% (29 of 42) of patients without PHTN improved to NYHA class I/II at follow-up. Kaplan-Meier survival of PHTN patients was 68.1% at 3 years, which was lower than patients without PHTN (81.4%; p = 0.44), but not statistically significant. Kaplan-Meier 3-year survival for all SVR patients was 76.6%.

CONCLUSIONS

Surgical ventricular restoration is a good treatment option in patients with advanced congestive heart failure and PHTN. Our early results are promising and should prompt further studies to confirm these findings.

摘要

背景

手术性心室修复（SVR）是治疗缺血性心肌病所致充血性心力衰竭的既定疗法。由于推测手术风险增加，肺动脉高压（PHTN）一直被视为SVR的禁忌证。然而，这些患者的预后以及SVR对PHTN的影响尚未得到具体评估。

方法

我们回顾性分析了2002年1月至2005年6月期间接受SVR的患者。根据术前心脏导管检查，将患者分为PHTN组（平均肺动脉压≥25mmHg）和无PHTN组（平均肺动脉压<25mmHg）。使用磁共振成像和超声心动图评估心脏功能。随访率为100%。

结果

69例患者因充血性心力衰竭接受了SVR。36%（69例中的25例）术前患有PHTN。术前，PHTN患者的射血分数显著低于无PHTN患者（21.1%对30.0%；p = 0.005），左心室收缩末期容积指数更大（119.0对88.7mL/m2；p = 0.04）。所有PHTN患者和95.5%（44例中的42例）无PHTN组患者术前均为纽约心脏协会（NYHA）III/IV级。PHTN组有1例手术死亡。手术性心室修复显著改善了PHTN患者的心脏功能和肺动脉压力。两组术后心脏功能相似。72%（25例中的18例）的PHTN患者和69.0%（42例中的29例）无PHTN患者在随访时改善为NYHA I/II级。PHTN患者的3年Kaplan-Meier生存率为68.1%（低于无PHTN患者的81.4%；p = 0.44），但无统计学意义。所有SVR患者的3年Kaplan-Meier生存率为76.6%。