Delgado Diego H, Ross Heather J, Rao Vivek
Division of Cardiology and Transplantation, Toronto General Hospital, Toronto, Canada.
Can J Cardiol. 2007 Jun;23(8):657-61. doi: 10.1016/s0828-282x(07)70228-3.
Left ventricular assist devices (LVADs) are an important adjunct to the management of end-stage heart failure patients. Uncertainty remains regarding whether to remove an LVAD in a clinically stable, asymptomatic patient who displays signs of ventricular recovery.
To evaluate, from a patient's perspective, the quality-adjusted life expectancy of an LVAD explantation.
A Markov state transition model was used to assess the benefits of two strategies: remove an LVAD or continue the LVAD support. Effectiveness was measured in quality-adjusted life months. Utility and probability scores were derived from the literature and expert opinion. The base case focused on a 35-year-old man with dilated cardiomyopathy, an implantable LVAD and signs of ventricular recovery, with New York Heart Association class I heart failure symptoms.
In the base case, continuing LVAD support was strongly preferred and improved quality-adjusted life expectancy by nine quality-adjusted life months. In sensitivity analyses for the utility post-transplant, removal of the device would have been preferred if the utility was less than 0.7. The model was also sensitive to the probability of late complications post-LVAD implantation. As the probability of complications increased (greater than 28%), the preferred strategy was to remove the LVAD.
Continuing LVAD support in asymptomatic patients with signs of ventricular recovery appears to be the preferred strategy for conveying greater quality-adjusted life months compared with LVAD explantation. As the probability of complications after LVAD implantation increases, the preferred strategy is to remove the LVAD.
左心室辅助装置(LVADs)是终末期心力衰竭患者治疗的重要辅助手段。对于临床稳定、无症状但显示心室恢复迹象的患者是否移除LVAD,仍存在不确定性。
从患者角度评估LVAD移除后质量调整后的预期寿命。
采用马尔可夫状态转移模型评估两种策略的益处:移除LVAD或继续LVAD支持。以质量调整生命月衡量有效性。效用和概率评分来自文献和专家意见。基础案例聚焦于一名35岁扩张型心肌病男性患者,植入了LVAD且有心室恢复迹象,纽约心脏协会心功能分级为I级心力衰竭症状。
在基础案例中,强烈倾向于继续LVAD支持,质量调整后的预期寿命提高了9个质量调整生命月。在移植后效用的敏感性分析中,如果效用小于0.7,则倾向于移除装置。该模型对LVAD植入后晚期并发症的概率也很敏感。随着并发症概率增加(大于28%),首选策略是移除LVAD。
对于有心室恢复迹象的无症状患者,与移除LVAD相比,继续LVAD支持似乎是获得更多质量调整生命月的首选策略。随着LVAD植入后并发症概率增加,首选策略是移除LVAD。