Hilty Matthias Peter, Franzen Daniel Peter, Wyss Christophe, Biaggi Patric, Maggiorini Marco
Medical Intensive Care Unit, University Hospital of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland.
Department of Pulmonology, University Hospital of Zurich, Zurich, Switzerland.
Ann Intensive Care. 2017 Aug 22;7(1):86. doi: 10.1186/s13613-017-0307-0.
Transpulmonary thermodilution is recommended in the treatment of critically ill patients presenting with complex shock. However, so far it has not been validated in hemodynamically stable patients with heart disease.
We assessed the validity of cardiac output, global end-diastolic volume index (GEDVI), an established marker of preload thought to reflect the volume of all four heart chambers, global ejection fraction (GEF) and cardiac function index (CFI) as variables of cardiac function, and extravascular lung water index (EVLWI) as indicator of pulmonary edema in 29 patients undergoing elective left and right heart catheterization including left ventricular angiography with stable coronary heart disease and normal cardiac function (controls, n = 11), moderate-to-severe aortic valve stenosis (AS, n = 10), or dilated cardiomyopathy (DCM, n = 8).
Cardiac output was similar in controls, AS, and DCM, with good correlation between transpulmonary thermodilution and pulmonary artery catheter using the Fick method (r = 0.69, p < 0.0001). Left ventricular end-diastolic volume was normal in controls and AS, but significantly higher in DCM (104 ± 37 vs 135 ± 63 vs 234 ± 24 ml, p < 0.01). GEDVI did not differentiate between patients with normal and patients with enlarged left ventricular end-diastolic volume (848 ± 128 vs 882 ± 213 ml m, p = 0.60). No difference in GEF and CFI was found between patients with normal and patients with reduced left ventricular ejection fraction. Patients with AS but not DCM had higher EVLWI than controls (9 ± 2 vs 12 ± 4 vs 11 ± 3 ml kg, p = 0.04), while there was only a trend in pulmonary artery occlusion pressure (8 ± 3 vs 10 ± 5 vs 14 ± 7 mmHg, p = 0.05).
Cardiac output measurement by transpulmonary thermodilution is unaffected by differences in ventricular size and outflow obstruction. However, GEDVI did not identify markedly enlarged left ventricular end-diastolic volumes, and neither GEF nor CFI reflected the increased heart chamber volumes and markedly impaired left ventricular function in patients with DCM. In contrast, EVLWI is probably a sensitive marker of subclinical pulmonary edema particularly in patients with elevated left-ventricular-filling pressure irrespective of differences in left ventricular function.
经肺热稀释法被推荐用于治疗伴有复杂休克的危重症患者。然而，迄今为止，其在血流动力学稳定的心脏病患者中尚未得到验证。
我们评估了心输出量、全心舒张末期容积指数（GEDVI）、一种被认为可反映所有四个心腔容积的既定前负荷标志物、全心射血分数（GEF）和心功能指数（CFI）作为心功能变量，以及血管外肺水指数（EVLWI）作为肺水肿指标在29例接受择期左右心导管检查（包括左心室造影）的患者中的有效性，这些患者患有稳定型冠心病且心功能正常（对照组，n = 11）、中重度主动脉瓣狭窄（AS，n = 10）或扩张型心肌病（DCM，n = 8）。
对照组、AS组和DCM组的心输出量相似，经肺热稀释法与采用Fick法的肺动脉导管测量结果之间具有良好的相关性（r = 0.69，p < 0.0001）。对照组和AS组的左心室舒张末期容积正常，但DCM组显著更高（104 ± 37 vs 135 ± 63 vs 234 ± 24 ml，p < 0.01）。GEDVI未能区分左心室舒张末期容积正常和增大的患者（848 ± 128 vs 882 ± 213 ml/m²，p = 0.60）。左心室射血分数正常和降低的患者之间，GEF和CFI无差异。AS组而非DCM组的患者EVLWI高于对照组（9 ± 2 vs 12 ± 4 vs 11 ± 3 ml/kg，p = 0.04），而肺动脉闭塞压仅有升高趋势（8 ± 3 vs 10 ± 5 vs 14 ± 7 mmHg，p = 0.05）。
经肺热稀释法测量心输出量不受心室大小和流出道梗阻差异的影响。然而，GEDVI未能识别出明显增大的左心室舒张末期容积，且GEF和CFI均未反映DCM患者心腔容积增加及左心室功能明显受损的情况。相比之下，EVLWI可能是亚临床肺水肿的敏感标志物，尤其是在左心室充盈压升高的患者中，而与左心室功能差异无关。
