Adamson R M, Dembitsky W P, Reichman R T, Moreno-Cabral R J, Daily P O
Department of Surgery, Sharp Memorial Hospital, University of California, San Diego.
J Thorac Cardiovasc Surg. 1989 Nov;98(5 Pt 2):915-20; discussion 920-1.
Our 6-year experience with ventricular assist devices was reviewed to determine variables associated with improved survival. Forty-three patients (mean age 62 +/- 14 years) were supported after balloon pumping and pressors proved inadequate. Twenty-eight patients could not be weaned from cardiopulmonary bypass, 12 patients deteriorated in the intensive care unit after cardiac surgery, and three had a bridged to transplantation. Overall, 47% (20/43) of patients could not be weaned from the ventricular assist devices, and 26% (11/43) were weaned but died before discharge, resulting in a hospital mortality rate of 72% (31/43). The remaining 28% (12/43) of patients were discharged and have survived 9 to 62 months. Early institution of ventricular assist devices (p less than 0.01), use of biventricular support (p less than 0.01), use of ventricular assist devices as a bridge to transplantation (p less than 0.05), and increased operator experience (p less than 0.05) were associated with improved survival. When patient and disease-related variables were analyzed, only age less than 60 years (p less than 0.01) and unexpectedly preoperative myocardial infarction associated with shock (p less than 0.05) were related to improved survival. Death was caused by insufficient ventricular recovery, stroke, multiple organ system failure, sepsis, or a combination of these complications. During long-term follow-up, two patients have died of congestive heart failure, and one is significantly impaired from a stroke. Two other patients are functional class III and seven patients are class I. Although hospital mortality was high (72%), the use of ventricular assist device support resulted in overall "long-term" survival of a significant percentage (28%) of patients, 47% (8/17), in the past 12 months, all of whom would have died without it. Therefore we currently recommend a trial of ventricular assist devices support for most patients who fail to be weaned from cardiopulmonary bypass, deteriorate in the perioperative period, and as a bridge to transplantation. Long-term survival is determined by the complications from ventricular assist devices support and functional status of the remaining myocardium.
回顾我们6年使用心室辅助装置的经验，以确定与生存率提高相关的变量。43例患者（平均年龄62±14岁）在球囊泵血和血管加压药治疗效果不佳后接受了心室辅助装置支持。28例患者无法脱离体外循环，12例患者在心脏手术后重症监护病房病情恶化，3例患者过渡到移植。总体而言，47%（20/43）的患者无法脱离心室辅助装置，26%（11/43）的患者虽脱离装置但在出院前死亡，导致医院死亡率为72%（31/43）。其余28%（12/43）的患者出院，存活9至62个月。早期使用心室辅助装置（p<0.01）、使用双心室支持（p<0.01）、将心室辅助装置作为移植过渡手段（p<0.05）以及术者经验增加（p<0.05）与生存率提高相关。当分析患者和疾病相关变量时，只有年龄小于60岁（p<0.01）以及术前意外发生与休克相关的心肌梗死（p<0.05）与生存率提高有关。死亡原因是心室恢复不足、中风、多器官系统衰竭、败血症或这些并发症的组合。在长期随访中，2例患者死于充血性心力衰竭，1例因中风严重受损。另外2例患者心功能为Ⅲ级，7例为Ⅰ级。尽管医院死亡率很高（72%），但使用心室辅助装置支持使相当比例（28%）的患者获得了总体“长期”生存，在过去12个月中有47%（8/17）的患者存活，若不使用该装置他们都会死亡。因此，我们目前建议对大多数无法脱离体外循环、围手术期病情恶化以及作为移植过渡的患者尝试使用心室辅助装置支持。长期生存取决于心室辅助装置支持的并发症以及剩余心肌的功能状态。
