Department of Internal Medicine, Saarland University Medical Centre, Homburg/Saar, Germany.
Eur J Heart Fail. 2014 Oct;16(10):1082-8. doi: 10.1002/ejhf.158. Epub 2014 Sep 9.
In patients after the Fontan procedure, assessment of a failing Fontan circuit is difficult. Natriuretic peptides failed to be reliable markers of functional status or systemic ventricular function in this patient cohort. The aim of the study was to assess the clinical utility of mid-regional pro-adrenomedullin (MR-proADM) in patients after the Fontan procedure.
Plasma MR-proADM levels were measured in 53 patients after the Fontan procedure and compared with clinical status, echocardiographic, and laboratory parameters including NT-proBNP. Median MR-proADM levels were 0.668 nmol/L in patients with a failing Fontan circuit as compared with 0.357 nmol/L in those without Fontan failure (P = 0.001). Levels of MR-proADM were significantly related to the presence of Fontan failure (r = 0.444, P = 0.001), NYHA class (r = 0.434, P < 0.001), and γ-glutamyltransferase levels (r = 0.554, P < 0.001). According to receiver operating characteristic (ROC) curve analysis, Fontan failure was best predicted by MR-proADM [area under the curve (AUC) 0.985, P = 0.001], NT-proBNP (AUC 0.947, P = 0.003), NYHA class (AUC 0.962, P = 0.002), and the inspiratory/expiratory ratio of the inferior vena cava diameter (AUC 0.973, P = 0.007). The optimal cut-off of MR-proADM for the prediction of Fontan failure was 0.520 nmol/L with a sensitivity of 100%, specificity of 93.9%, positive predictive value of 57.1%, negative predictive value of 100%, and overall accuracy of 94.3%. However, the data should also be validated in a larger cohort of patients.
Serial measurements of MR-proADM levels may help identify patients at risk for a failing Fontan circulation especially when exceeding 0.520 nmol/L. In these patients, intensified medical care should be considered to prevent further clinical deterioration.
在接受 Fontan 手术的患者中，评估功能不良的 Fontan 循环较为困难。在该患者队列中，利钠肽不能作为心功能状态或系统性心室功能的可靠标志物。本研究旨在评估中肽段原肾上腺髓质素（MR-proADM）在 Fontan 手术后患者中的临床应用价值。
测量了 53 例接受 Fontan 手术后患者的血浆 MR-proADM 水平，并将其与临床状态、超声心动图和包括 NT-proBNP 在内的实验室参数进行比较。与无 Fontan 衰竭的患者（0.357 nmol/L）相比，Fontan 循环衰竭患者的中位 MR-proADM 水平为 0.668 nmol/L（P=0.001）。MR-proADM 水平与 Fontan 衰竭的存在显著相关（r=0.444，P=0.001），与 NYHA 分级（r=0.434，P<0.001）和γ-谷氨酰转移酶水平（r=0.554，P<0.001）也显著相关。根据受试者工作特征（ROC）曲线分析，MR-proADM 对 Fontan 衰竭的预测最佳[曲线下面积（AUC）为 0.985，P=0.001]，其次是 NT-proBNP（AUC 为 0.947，P=0.003）、NYHA 分级（AUC 为 0.962，P=0.002）和下腔静脉吸气/呼气比（AUC 为 0.973，P=0.007）。预测 Fontan 衰竭的最佳 MR-proADM 截断值为 0.520 nmol/L，其灵敏度为 100%，特异性为 93.9%，阳性预测值为 57.1%，阴性预测值为 100%，总准确率为 94.3%。然而，这些数据还需要在更大的患者队列中进行验证。
MR-proADM 水平的连续测量可能有助于识别 Fontan 循环衰竭风险患者，特别是当水平超过 0.520 nmol/L 时。对于这些患者，应考虑加强医疗护理，以防止进一步的临床恶化。
