Kim JeongHye, Kuwata Seiko, Kurishima Clara, Iwamoto Yoichi, Ishido Hirotaka, Masutani Satoshi, Senzaki Hideaki
Division of Pediatric Cardiology, Saitama Medical Center, Saitama Medical University, Staff Office Building Room 101, 1981 Kamoda, Kawagoe, Saitama, 350-8550, Japan.
Heart Vessels. 2018 Jun;33(6):664-670. doi: 10.1007/s00380-017-1109-x. Epub 2018 Jan 8.
We tested our hypotheses that central venous pressure (CVP) shows an excessive increase in response to volume overload in Fontan circulation according to the extent of the reduction in venous capacitance (Cv), and that the maximum CVP after volume loading is associated with hepatic congestion. Changes in CVP after angiography (volume loading) were examined in 40 patients with Fontan circulation and 29 controls with biventricular circulation. CVP significantly increased with angiography in both groups, but the changes were much more evident in the Fontan group than in controls (3.3 ± 2.0 vs. 0.9 ± 1.4 mmHg, p = 0.0003). Multivariate analysis demonstrated that reduced Cv was the only significant determinant of CVP increase, independent of the amount of injected contrast medium, blood volume, pulmonary resistance, and ventricular diastolic stiffness (p < 0.05). Importantly, the use of a venodilator was associated with increased Cv and the resultant suppression of CVP elevation with volume load. In addition, CVP levels both at baseline (p = 0.02) and after volume loading (p = 0.01) were weakly but significantly correlated with the plasma levels of γ-glutamyl transpeptidase, a marker of hepatic congestion; however, multivariate analysis revealed that the CVP level after volume loading was a more important determinant of hepatic congestion. The results of this study highlight the importance of assessing dynamic in addition to static CVP for a better understanding of Fontan circulation. The potential importance of Cv as a therapeutic target for improving Fontan physiology needs further elucidation.
在Fontan循环中，根据静脉容量（Cv）降低的程度，中心静脉压（CVP）对容量超负荷的反应会过度增加；并且容量负荷后CVP的最大值与肝充血有关。对40例Fontan循环患者和29例双心室循环对照者进行了血管造影（容量负荷）后CVP变化的检查。两组患者血管造影后CVP均显著升高，但Fontan组的变化比对照组更明显（3.3±2.0 vs. 0.9±1.4 mmHg，p = 0.0003）。多变量分析表明，Cv降低是CVP升高的唯一显著决定因素，与注入造影剂的量、血容量、肺阻力和心室舒张硬度无关（p < 0.05）。重要的是，使用血管扩张剂与Cv增加以及容量负荷导致的CVP升高受抑制有关。此外，基线时（p = 0.02）和容量负荷后（p = 0.01）的CVP水平与肝充血标志物γ-谷氨酰转肽酶的血浆水平呈弱但显著的相关性；然而，多变量分析显示，容量负荷后的CVP水平是肝充血更重要的决定因素。本研究结果强调了除静态CVP外，评估动态CVP对于更好理解Fontan循环的重要性。Cv作为改善Fontan生理学治疗靶点的潜在重要性需要进一步阐明。
