Department of Cardiology, Congenital Heart Disease and Electrotherapy, Teaching Ward of Cardiology,Silesian Medical University, Silesian Centre for Heart Diseases, Zabrze, Poland.
Kardiol Pol. 2012;70(8):769-73.
For over 40 years now orthotopic heart transplantation (OHT) has been the treatment of choice in patients with advanced heart failure. For many years patients undergoing OHT have been treated with the classical approach involving anastomosis of the donor atria with the recipient atria resulting in a heart in which the atria are enlarged. An alternative method for OHT is the bicaval anastomosis technique, which involves connecting both of the donor's venae cavae with the recipient's venae cavae.
To assess left ventricular (LV) filling in patients undergoing OHT using the classical (biatrial) versus bicaval approach.
We analysed 60 patients who had undergone OHT between 1 and 36 months before. Myocardial biopsy at echocardiography revealed grade 0 or 1A rejection in all the patients. All the patients were also in NYHA functional class I. The patients were divided in two groups: patients who had undergone biatrial anastomosis (Group 1, n = 40) and patients who had undergone bicaval OHT (Group 2, n = 20). In order to render the results independent of pre-OHT blood pressure values in the pulmonary circulation we assessed the values of right ventricular systolic pressure (RVSP), mean pulmonary artery pressure (PAP) and transpulmonary gradient (TPG) in all the patients before OHT. We assessed the following echocardiographic parameters: peak early filling velocity (E-wave), peak atrial filling velocity (A-wave), E-wave deceleration time, early diastolic mitral valve ring motion velocity (E'), E/E', isovolumetric relaxation time of the LV, duration of the A-wave, right atrial area and left atrial area, LV mass, LV mass index, LV end-diastolic and end-systolic dimension, and the severity of tricuspid regurgitation (TR).
The values of RVSP, PAP and TPG in the study groups before OHT did not differ significantly. The values of E (86.5 ± 12.5 vs. 67.3 ± 8.5; p < 0.001), E' (11.9 ± 1.1 vs. 10.9 ± 0.9; p = 0.003) and E/E' (7.4 ± 1.5 vs. 6.1 ± 0.85; p = 0.006) differed between the groups and were significantly higher in the group undergoing surgery using the biatrial approach. The duration of the A-wave was significantly longer in the group undergoing surgery using the bicaval approach (129.0 ± 5.1 vs. 136.7 ± 10.0; p = 0.001). There were no significant differences in the other parameters of LV filling. Right atrial area was significantly lower in the group undergoing surgery using the bicaval approach (19.2 ± 3.0 vs. 14.0 ± 2.0; p < 0.001). LV size, LV mass and LV mass index did not differ significantly between the groups. The lack of TR was more commonly observed in the group undergoing surgery using the bicaval approach at the limit of p = 0.05. Pacemaker implantation was required in 12 (30%) patients from the group undergoing surgery using the classical method and 2 (10%) patients from the group undergoing OHT using the bicaval approach (p = 0.04).
Certain echocardiographic parameters suggest a better LV filling in patients undergoing OHT using the bicaval approach. Preservation of the right atrial geometry in patients undergoing OHT using the bicaval approach plays an important role in LV filling.
40 多年来，原位心脏移植（OHT）一直是晚期心力衰竭患者的首选治疗方法。多年来，接受 OHT 的患者一直采用经典方法进行治疗，涉及供体心房与受体心房的吻合，导致心脏心房扩大。OHT 的另一种方法是双腔静脉吻合技术，涉及将供体的两个腔静脉与受体的腔静脉连接起来。
使用经典（双心房）与双腔静脉方法评估 OHT 患者的左心室（LV）充盈情况。
我们分析了 60 例在 1 至 36 个月前接受 OHT 的患者。心肌活检在超声心动图上显示所有患者的排斥反应均为 0 级或 1A 级。所有患者均处于 NYHA 心功能 I 级。患者分为两组：接受双心房吻合术的患者（组 1，n = 40）和接受双腔静脉 OHT 的患者（组 2，n = 20）。为了使结果独立于肺动脉循环中的 OHT 前血压值，我们评估了所有患者在 OHT 前的右心室收缩压（RVSP）、平均肺动脉压（PAP）和跨肺梯度（TPG）值。我们评估了以下超声心动图参数：峰值早期充盈速度（E 波）、峰值心房充盈速度（A 波）、E 波减速时间、二尖瓣环早期舒张运动速度（E'）、E/E'、LV 等容舒张时间、A 波持续时间、右心房面积和左心房面积、LV 质量、LV 质量指数、LV 舒张末期和收缩末期尺寸以及三尖瓣反流（TR）的严重程度。
研究组在 OHT 前的 RVSP、PAP 和 TPG 值无显著差异。E（86.5 ± 12.5 比 67.3 ± 8.5；p < 0.001）、E'（11.9 ± 1.1 比 10.9 ± 0.9；p = 0.003）和 E/E'（7.4 ± 1.5 比 6.1 ± 0.85；p = 0.006）的值在两组之间存在差异，并且在接受双心房手术的组中明显更高。接受双腔静脉手术的组中 A 波持续时间明显更长（129.0 ± 5.1 比 136.7 ± 10.0；p = 0.001）。LV 充盈的其他参数无显著差异。接受双腔静脉手术的组右心房面积明显较小（19.2 ± 3.0 比 14.0 ± 2.0；p < 0.001）。LV 大小、LV 质量和 LV 质量指数在两组之间无显著差异。接受双腔静脉手术的组中 TR 缺失更为常见，接近 p = 0.05。接受经典方法手术的患者中有 12 例（30%）需要植入起搏器，而接受双腔静脉方法手术的患者中有 2 例（10%）需要植入起搏器（p = 0.04）。
某些超声心动图参数表明，接受双腔静脉方法的 OHT 患者的 LV 充盈情况更好。接受双腔静脉 OHT 的患者保持右心房几何形状对 LV 充盈起着重要作用。
