Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, USA..
Am J Cardiol. 2012 Sep 15;110(6):857-61. doi: 10.1016/j.amjcard.2012.04.065. Epub 2012 Jun 7.
Mixed cohorts of patients with ischemic and nonischemic end-stage heart failure (HF) with a QRS duration of ≥120 ms and requiring intravenous inotropes do not appear to benefit from cardiac resynchronization therapy (CRT). However, CRT does provide greater benefit to patients with nonischemic cardiomyopathy and might, therefore, be able to reverse the HF syndrome in such patients who are inotrope dependent. To address this question, 226 patients with nonischemic cardiomyopathy who received a CRT-defibrillator and who had a left ventricular ejection fraction of ≤35% and QRS of ≥120 ms were followed up for the outcomes of death, transplantation, and ventricular assist device placement. Follow-up echocardiograms were performed in patients with ≥6 months of transplant- and ventricular assist device-free survival after CRT. The patients were divided into 3 groups: (1) never took inotropes (n = 180), (2) weaned from inotropes before CRT (n = 30), and (3) dependent on inotropes at CRT implantation (n = 16). At 47 ± 30 months of follow-up, the patients who had never taken inotropes had had the longest transplant- and ventricular assist device-free survival. The inotrope-dependent patients had the worst outcomes, and the patients weaned from inotropes experienced intermediate outcomes (p <0.0001). Reverse remodeling and left ventricular ejection fraction improvement followed a similar pattern. Among the patients weaned from and dependent on inotropes, a central venous pressure <10 mm Hg on right heart catheterization before CRT was predictive of greater left ventricular functional improvement, more profound reverse remodeling, and longer survival free of transplantation or ventricular assist device placement. In conclusion, inotrope therapy before CRT is an important marker of adverse outcomes after implantation in patients with nonischemic cardiomyopathy, with inotrope dependence denoting irreversible end-stage HF unresponsive to CRT.
患有缺血性和非缺血性终末期心力衰竭（HF）、QRS 持续时间≥120ms 且需要静脉正性肌力药物的混合患者似乎不能从心脏再同步治疗（CRT）中获益。然而，CRT 确实为非缺血性心肌病患者提供了更大的益处，因此，可能能够逆转依赖正性肌力药物的此类患者的 HF 综合征。为了解决这个问题，对 226 名接受 CRT 除颤器治疗的非缺血性心肌病患者进行了随访，这些患者的左心室射血分数≤35%，QRS≥120ms。对这些患者的死亡、移植和心室辅助装置放置的结果进行了随访。在 CRT 后≥6 个月无移植和心室辅助装置生存的患者中进行了超声心动图检查。将患者分为 3 组：（1）从未使用过正性肌力药物（n=180），（2）在 CRT 前已停用正性肌力药物（n=30），和（3）在 CRT 植入时依赖于正性肌力药物（n=16）。在 47±30 个月的随访中，从未使用过正性肌力药物的患者具有最长的移植和心室辅助装置无生存时间。依赖正性肌力药物的患者的结局最差，而停用正性肌力药物的患者的结局处于中间（p<0.0001）。逆转重构和左心室射血分数的改善也呈现出相似的模式。在已停用和依赖正性肌力药物的患者中，在 CRT 前右心导管检查中心静脉压<10mmHg 与更大的左心室功能改善、更明显的逆转重构和更长的无移植或心室辅助装置放置生存时间相关。总之，在非缺血性心肌病患者中，在 CRT 前使用正性肌力药物是植入后不良结局的一个重要标志物，依赖正性肌力药物表示 CRT 无法逆转的不可逆终末期 HF。
