Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Ann Thorac Surg. 2014 Apr;97(4):1348-55. doi: 10.1016/j.athoracsur.2013.12.029. Epub 2014 Feb 22.
Thoracic radiation leads to radiation-associated cardiac disease (RACD), associated with substantial cardiac morbidity and mortality, often requiring complex cardiothoracic surgery. In patients with RACD, along with valvular lesions, the aorto-mitral curtain (AMC, junction between base of anterior mitral leaflet and aortic root) thickness is increased on transthoracic echocardiography. We sought to identify clinical and transthoracic echocardiography predictors of long-term mortality in patients with RACD.
We studied 173 patients with RACD (75% women, 63±14 years, 53% with breast cancer, 27% with Hodgkin lymphoma; mean time from radiation, 18±12 years), who underwent cardiothoracic surgery (26% redo) between 2000 and 2003. Clinical, transthoracic echocardiography (along with AMC), and surgical variables were recorded. Preoperative EuroSCORE and all-cause mortality were recorded.
Mean left ventricular ejection fraction, right systolic ventricular pressure, and AMC thickness were 0.49±0.13, 41±15 mm Hg, and 0.54±0.2 cm, respectively. Fifty-one percent of patients had II+ mitral regurgitation or greater, 29% patients had II+ aortic regurgitation or greater, 23% patients had severe aortic stenosis, and 34% patients had II+ tricuspid regurgitation or greater. In 7.6±3 years of follow-up, there were 95 (55%) deaths, with a 30-day mortality rate of only 7 (4%). Absence of β-blockers (hazard ratio, 0.49; 95% confidence interval, 0.31 to 0.79), aspirin (hazard ratio, 0.53; 95% confidence interval, 0.33 to 0.84), higher EuroSCORE (hazard ratio, 1.11; 95% confidence interval, 1.02 to 1.21), and greater AMC thickness (hazard ratio, 5.75; 95% confidence interval, 1.57 to 21.03; all p<0.01) independently predicted mortality. Aorto-mitral curtain thickness of at least 0.6 cm was associated with significantly increased mortality.
Patients with RACD undergoing cardiothoracic surgery have high long-term mortality, which is independently predicted by AMC thickness, a higher preoperative risk score, and lack of cardioprotective medications.
胸部放疗可导致放射性心脏疾病（RACD），这与大量的心脏发病率和死亡率有关，通常需要进行复杂的心胸外科手术。在 RACD 患者中，除了瓣膜病变外，经胸超声心动图还显示主动脉二尖瓣幕（AMC，前二尖瓣叶基部与主动脉根部之间的交界处）厚度增加。我们旨在确定 RACD 患者长期死亡率的临床和经胸超声心动图预测因素。
我们研究了 173 例 RACD 患者（75%为女性，年龄 63±14 岁，53%为乳腺癌，27%为霍奇金淋巴瘤；放疗后平均时间 18±12 年），这些患者于 2000 年至 2003 年间接受了心胸外科手术（26%为再次手术）。记录临床、经胸超声心动图（包括 AMC）和手术变量。记录术前欧洲心脏手术风险评分（EuroSCORE）和全因死亡率。
平均左心室射血分数、右心室收缩压和 AMC 厚度分别为 0.49±0.13、41±15mmHg 和 0.54±0.2cm。51%的患者存在 II+或更严重的二尖瓣反流，29%的患者存在 II+或更严重的主动脉瓣反流，23%的患者存在严重的主动脉瓣狭窄，34%的患者存在 II+或更严重的三尖瓣反流。在 7.6±3 年的随访中，共有 95 例（55%）死亡，30 天死亡率仅为 7 例（4%）。β受体阻滞剂（危险比，0.49；95%置信区间，0.31 至 0.79）、阿司匹林（危险比，0.53；95%置信区间，0.33 至 0.84）、较高的 EuroSCORE（危险比，1.11；95%置信区间，1.02 至 1.21）和较高的 AMC 厚度（危险比，5.75；95%置信区间，1.57 至 21.03；均 P<0.01）是独立预测死亡率的因素。AMC 厚度至少为 0.6cm 与死亡率显著增加相关。
接受心胸外科手术的 RACD 患者具有较高的长期死亡率，其独立预测因素为 AMC 厚度、术前风险评分较高和缺乏心脏保护药物。
