Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
Department of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
J Thorac Cardiovasc Surg. 2017 Aug;154(2):572-582. doi: 10.1016/j.jtcvs.2017.02.070. Epub 2017 Apr 11.
Patients with a borderline left ventricular hypoplasia in the hypoplastic left heart syndrome variant or an unbalanced atrioventricular canal who undergo initial single-ventricle palliation may be candidates for biventricular (BiV) conversion following left ventricle (LV) recruitment procedures. We investigated associations among preoperative parameters and postoperative outcomes in patients undergoing BiV conversion.
We performed a retrospective review of patients who underwent BiV conversion to determine variables associated with clinical outcomes. Predictor variables included cardiac diagnosis, age and weight, LV dimension, LV end diastolic volume, LV mass, preoperative LV end diastolic pressure (LVEDP), and preoperative left atrial pressure. Primary outcome was a composite of death, heart transplant, or BiV takedown.
Of 51 patients, 11 experienced primary outcome (22%). Patients with hypoplastic left heart syndrome variant were more likely to experience primary outcome than those with an unbalanced atrioventricular canal (30% vs 6%; P = .03). Receiver operating characteristic analysis demonstrated that preoperative LVEDP had good predictive accuracy in classifying patients with and without the primary outcome (area under the curve, 0.757; 95% confidence interval, 0.594-0.919; P = .012). The Youden J-index indicated a cutoff of LVEDP ≥ 13 mm Hg as optimal for predicting the primary outcome. Multivariable Cox regression demonstrated that LVEDP ≥ 13 mm Hg (adjusted hazard ratio, 4.00; P = .037) and postoperative right ventricle pressure > 3/4 (adjusted hazard ratio, 21.75; P < .001) were significantly associated with primary outcome, independent of age, weight, and diagnosis.
Elevated preoperative LVEDP is a risk factor for suboptimal postoperative hemodynamic parameters and adverse outcome following BiV conversion from single-ventricle palliation.
在左心发育不良综合征变异型或房室通道不平衡的患者中，行初始单心室姑息治疗后，左心室（LV）招募术后可能会成为双心室（BiV）转换的候选者。我们研究了接受 BiV 转换的患者术前参数与术后结局之间的关系。
我们对接受 BiV 转换的患者进行了回顾性研究，以确定与临床结局相关的变量。预测变量包括心脏诊断、年龄和体重、LV 直径、LV 舒张末期容积、LV 质量、术前 LV 舒张末期压（LVEDP）和术前左心房压。主要结局是死亡、心脏移植或 BiV 拆除的复合结局。
在 51 例患者中，有 11 例（22%）发生主要结局。左心发育不良综合征变异型患者发生主要结局的可能性大于房室通道不平衡患者（30%比 6%；P=0.03）。受试者工作特征分析表明，术前 LVEDP 对预测有无主要结局的患者具有良好的预测准确性（曲线下面积，0.757；95%置信区间，0.594-0.919；P=0.012）。Youden J 指数表明，LVEDP≥13mmHg 是预测主要结局的最佳截断值。多变量 Cox 回归显示，LVEDP≥13mmHg（调整后的危险比，4.00；P=0.037）和术后右心室压>3/4（调整后的危险比，21.75；P<0.001）与主要结局显著相关，独立于年龄、体重和诊断。
术前 LVEDP 升高是双心室转换后术后血流动力学参数不理想和不良结局的危险因素。
