Utah Transplantation Affiliated Hospitals (UTAH) Cardiac Transplant Program, Divisions of Cardiovascular Medicine and Cardiovascular Surgery, University of Utah Health Sciences Center, Salt Lake VA Medical Center, Intermountain Medical Center, Salt Lake City, UT, USA.
Nora Eccles Harrison Cardiovascular Research and Training Institution (CVRTI), Salt Lake City, UT, USA.
Eur J Heart Fail. 2018 Jan;20(1):164-174. doi: 10.1002/ejhf.1018. Epub 2017 Nov 1.
Adjuvant heart failure (HF) drug therapy in patients undergoing chronic mechanical circulatory support (MCS) is often used in conjunction with a continuous-flow left ventricular assist device (LVAD), but its potential impact is not well defined. The objective of the present study was to examine the effects of conventional HF drug therapy on myocardial structure and function, peripheral organ function and the incidence of adverse events in the setting of MCS.
Patients with chronic HF requiring LVAD support were prospectively enrolled. Paired myocardial tissue samples were obtained prior to LVAD implantation and at transplantation for histopathology. The Meds group comprised patients treated with neurohormonal blocking therapy (concurrent beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and aldosterone antagonist), and the No Meds group comprised patients on none of these. Both the Meds (n = 37) and No Meds (n = 44) groups experienced significant improvements in cardiac structure and function over the 6 months following LVAD implantation. The degree of improvement was greater in the Meds group, including after adjustment for baseline differences. There were no differences between the two groups in arrhythmias, end-organ injury, or neurological events. In patients with high baseline pre-LVAD myocardial fibrosis, treatment with HF drug therapy was associated with a reduction in fibrosis.
Clinical and histopathological evidence showed that adjuvant HF drug therapy was associated with additional favourable effects on the structure and function of the unloaded myocardium that extended beyond the beneficial effects attributed to LVAD-induced unloading alone. Adjuvant HF drug therapy did not influence the incidence of major post-LVAD adverse events during the follow-up period.
在接受慢性机械循环支持（MCS）的患者中，辅助心力衰竭（HF）药物治疗通常与连续流左心室辅助装置（LVAD）联合使用，但其潜在影响尚不清楚。本研究的目的是研究在 MCS 中，常规 HF 药物治疗对心肌结构和功能、外周器官功能以及不良事件发生率的影响。
前瞻性招募需要 LVAD 支持的慢性 HF 患者。在 LVAD 植入前和移植时获取配对的心肌组织样本进行组织病理学检查。Meds 组包括接受神经激素阻断治疗（同时使用β受体阻滞剂、血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂和醛固酮拮抗剂）的患者，No Meds 组包括未接受这些治疗的患者。在 LVAD 植入后 6 个月内，Meds 组（n=37）和 No Meds 组（n=44）的心脏结构和功能均显著改善。Meds 组的改善程度更大，包括在调整基线差异后。两组在心律失常、终末器官损伤或神经事件方面无差异。在基线前 LVAD 心肌纤维化较高的患者中，HF 药物治疗与纤维化减少相关。
临床和组织病理学证据表明，辅助 HF 药物治疗与卸载心肌结构和功能的额外有利影响相关，这些影响超出了 LVAD 诱导卸载本身的有益影响。辅助 HF 药物治疗在随访期间并未影响 LVAD 后主要不良事件的发生率。
