右心室对脉动负荷的反应与左心室辅助装置后早期右心衰竭和死亡率有关。
Right ventricular response to pulsatile load is associated with early right heart failure and mortality after left ventricular assist device.
机构信息
Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
出版信息
J Heart Lung Transplant. 2017 Jan;36(1):97-105. doi: 10.1016/j.healun.2016.06.015. Epub 2016 Jun 24.
BACKGROUND
Right ventricular (RV) adaptation to afterload is crucial for patients undergoing continuous-flow left ventricular assist device (cf-LVAD) implantation. We hypothesized that stratifying patients by RV pulsatile load, using pulmonary arterial compliance (PAC), and RV response to load, using the ratio of central venous to pulmonary capillary wedge pressure (CVP:PCWP), would identify patients at high risk for early right heart failure (RHF) and 6-month mortality after cf-LVAD.
METHODS
During the period from January 2008 to June 2014, we identified 151 patients at our center with complete hemodynamics prior to cf-LVAD. Pulsatile load was estimated using PAC indexed to body surface area (BSA), according to the formula: indexed PAC (PACi) = [SV / (PA - PA)] / BSA, where SV is stroke volume and PA is pulmonary artery. Patients were divided into 4 hemodynamic groups by PACi and CVP:PCWP. RHF was defined as the need for unplanned RVAD, inotropic support ≥14 days or death due to RHF within 14 days. Risk factors for RHF and 6-month mortality were examined using logistic regression and Cox proportional hazards modeling.
RESULTS
Sixty-one patients (40.4%) developed RHF and 34 patients (22.5%) died within 6 months. Patients with RHF had lower PACi (0.92 vs 1.17 ml/mm Hg/m, p = 0.008) and higher CVP:PCWP (0.48 vs 0.37, p = 0.001). Higher PACi was associated with reduced risk of RHF (adjusted odds ratio [adj-OR] 0.61, 95% confidence interval [CI] 0.39 to 0.94, p = 0.025) and low PACi with increased risk of 6-month mortality (adjusted hazard ratio [adj-HR] 3.18, 95% CI 1.40 to 7.25, p = 0.006). Compared to patients with low load (high PACi) and adequate right heart response to load (low CVP:PCWP), patients with low PACi and high CVP:PCWP had an increased risk of RHF (OR 4.74, 95% CI 1.23 to 18.24, p = 0.02) and 6-month mortality (HR 8.68, 95% CI 2.79 to 26.99, p < 0.001).
CONCLUSIONS
A hemodynamic profile combining RV pulsatile load and response to load identifies patients at high risk for RHF and 6-month mortality after cf-LVAD.
背景
右心室（RV）适应后负荷对于接受连续流动左心室辅助装置（cf-LVAD）植入的患者至关重要。我们假设通过肺动脉顺应性（PAC）对 RV 脉动负荷进行分层，并通过中心静脉压与肺毛细血管楔压（CVP：PCWP）的比值来评估 RV 对负荷的反应，可以识别出 cf-LVAD 后早期发生右心衰竭（RHF）和 6 个月死亡率高的患者。
方法
在 2008 年 1 月至 2014 年 6 月期间，我们在中心确定了 151 名 cf-LVAD 前具有完整血流动力学的患者。脉动负荷通过 PAC 除以体表面积（BSA）进行估计，根据公式：指数 PAC（PACi）=[SV/（PA-PA）]/BSA，其中 SV 是心排量，PA 是肺动脉。根据 PACi 和 CVP：PCWP 将患者分为 4 个血流动力学组。RHF 定义为需要计划外 RVAD、14 天内需要正性肌力支持≥14 天或 14 天内因 RHF 死亡。使用逻辑回归和 Cox 比例风险模型检查 RHF 和 6 个月死亡率的危险因素。
结果
61 名患者（40.4%）发生 RHF，34 名患者（22.5%）在 6 个月内死亡。发生 RHF 的患者 PACi 较低（0.92 对 1.17 ml/mm Hg/m，p=0.008），CVP：PCWP 较高（0.48 对 0.37，p=0.001）。较高的 PACi 与 RHF 风险降低相关（调整后的优势比[adj-OR]0.61，95%置信区间[CI]0.39 至 0.94，p=0.025），而较低的 PACi 与 6 个月死亡率增加相关（调整后的危险比[adj-HR]3.18，95%CI 1.40 至 7.25，p=0.006）。与低负荷（高 PACi）和右心对负荷的适当反应（低 CVP：PCWP）患者相比，低 PACi 和高 CVP：PCWP 患者发生 RHF 的风险增加（OR 4.74，95%CI 1.23 至 18.24，p=0.02）和 6 个月死亡率（HR 8.68，95%CI 2.79 至 26.99，p<0.001）。
结论
RV 脉动负荷与对负荷的反应相结合的血流动力学特征可识别出 cf-LVAD 后发生 RHF 和 6 个月死亡率高的患者。
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