接受左心室辅助装置支持的晚期心力衰竭患者的术前和术后与神经并发症相关的危险因素。
Pre-operative and post-operative risk factors associated with neurologic complications in patients with advanced heart failure supported by a left ventricular assist device.
机构信息
Division of Cardiology, Department of Medicine, Department of Surgery, Columbia University Medical Center, New York, New York, USA.
出版信息
J Heart Lung Transplant. 2012 Jan;31(1):1-8. doi: 10.1016/j.healun.2011.08.014. Epub 2011 Oct 8.
BACKGROUND
Neurologic complications (NCs) are the major adverse events after left ventricular assist device (LVAD) surgery. Pre-operative and post-operative factors associated with NCs in patients with LVADs were investigated.
METHODS
We reviewed 307 consecutive patients undergoing LVAD surgery (167 HeartMate I and 140 HeartMate II devices) at Columbia University Medical Center between November 2000 and December 2010. Clinical characteristics and hemodynamic and laboratory indexes were analyzed. NC was defined according to the Interagency Registry for Mechanically Assisted Circulatory Support definition of neurologic dysfunction, including transient ischemic attack (TIA) and ischemic or hemorrhagic cerebrovascular accident (CVA).
RESULTS
NCs developed in 43 patients (14.0%) at 91.8 ± 116.3 days post-operatively. The frequency of NC development was similar in HeartMate I and II patients. Patients with NC showed a higher frequency of pre-LVAD CVA history (27.9% vs 15.5%, p = 0.046), lower pre-operative sodium (129.0 ± 7.0 vs 132.1 ± 8.1 mg/dl, p = 0.018) and albumin concentrations (3.5 ± 0.7 vs 3.7 ± 0.6 mg/dl, p = 0.049), lower post-operative hematocrit (34.9% ± 5.1% vs 37.8% ± 6.1%, p = 0.0034), sodium (131.6 ± 7.7 vs 134.4 ± 6.4 mg/dl, p = 0.010) and albumin concentrations (3.7 ± 0.5 vs 3.9 ± 0.5 mg/dl, p = 0.0016), and higher frequency of post-operative infection (39.5% vs 19.3%, p = 0.003) than those without NC. Multiple regression analysis revealed that CVA history (odds ratio, 2.37, 95% confidence interval, 1.24-5.29; p = 0.011) and post-operative infection (odds ratio, 2.99, 95% confidence interval, 1.16-10.49; p = 0.011) were highly associated with NC development. The combination of CVA history, pre-operative and post-operative sodium and albumin, and post-operative hematocrit and infection could discriminate patients developing NCs with a probability of 76.6%.
CONCLUSIONS
Previous stroke, persistent malnutrition and inflammation, severity of heart failure, and post-LVAD infections are key factors associated with development of NCs after LVAD implantation.
背景
神经并发症（NCs）是左心室辅助装置（LVAD）手术后的主要不良事件。研究了与 LVAD 患者 NC 相关的术前和术后因素。
方法
我们回顾了 2000 年 11 月至 2010 年 12 月期间在哥伦比亚大学医学中心接受 LVAD 手术的 307 例连续患者（167 例 HeartMate I 和 140 例 HeartMate II 装置）。分析了临床特征、血流动力学和实验室指标。根据机械循环辅助支持机构间注册定义的神经功能障碍，包括短暂性脑缺血发作（TIA）和缺血性或出血性脑血管意外（CVA），将 NC 定义为 NC。
结果
43 例（14.0%）患者在术后 91.8±116.3 天发生 NCs。HeartMate I 和 II 患者 NC 发生率相似。发生 NC 的患者有更高的 LVAD 前 CVA 病史发生率（27.9% vs. 15.5%，p=0.046），更低的术前钠浓度（129.0±7.0 vs. 132.1±8.1mg/dl，p=0.018）和白蛋白浓度（3.5±0.7 vs. 3.7±0.6mg/dl，p=0.049），更低的术后血细胞比容（34.9%±5.1% vs. 37.8%±6.1%，p=0.0034），钠浓度（131.6±7.7 vs. 134.4±6.4mg/dl，p=0.010）和白蛋白浓度（3.7±0.5 vs. 3.9±0.5mg/dl，p=0.0016），以及更高的术后感染发生率（39.5% vs. 19.3%，p=0.003）。多因素回归分析显示，CVA 病史（优势比，2.37，95%置信区间，1.24-5.29；p=0.011）和术后感染（优势比，2.99，95%置信区间，1.16-10.49；p=0.011）与 NC 发展高度相关。CVA 病史、术前和术后钠及白蛋白、术后血细胞比容和感染的组合可区分发生 NC 的患者，其概率为 76.6%。
结论
既往卒中、持续营养不良和炎症、心力衰竭严重程度以及 LVAD 后感染是与 LVAD 植入后 NC 发生相关的关键因素。
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