Section of Cardiac and Thoracic Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, Illinois.
Section of Cardiology, Department of Medicine, The University of Chicago Medicine, Chicago, Illinois.
Ann Thorac Surg. 2018 Dec;106(6):1789-1796. doi: 10.1016/j.athoracsur.2018.06.075. Epub 2018 Aug 24.
This retrospective single-institutional study investigated the effect of significant valvular regurgitation after left ventricular assist device (LVAD) implantation and the role of concomitant valve surgery during LVAD surgery.
All patients receiving an LVAD (HeartMate II; Abbott, Abbott Park, IL) during 2008 and 2015 were enrolled. The cohort was divided into two groups based on the valve status at the end of the operation: patients without significant valvular regurgitation (no-VR) and those with significant valvular regurgitation (residual-VR).
An LVAD was implanted in 270 patients. Of these, 233 had significant preoperative valve disease(s), and 180 (66.6%) received concomitant valve interventions (35 aortic, 90 mitral, 138 tricuspid). At the completion of the LVAD operation, 204 had no-VR and 66 had residual-VR. Short-term outcomes were similar in two groups, except for longer cardiopulmonary bypass time in the no-VR group (149 minutes) than in the residual-VR group (132 minutes, p = 0.038). During follow-up, mean pulmonary artery pressure (24 mm Hg in no-VR vs 27 mm Hg in residual-VR; p = 0.018) and pulmonary vascular resistance (1.8 Wood units in no-VR vs 2.7 Wood units in residual-VR, p = 0.008) significantly improved in no-VR group compared with the residual-VR group. Survival and heart failure admission-free rates at 1 year were significantly superior in the no-VR group compared with the residual-VR group (1-year survival: 72% ± 3% No-VR vs 55% ± 6% residual-VR; log-rank p = 0.026; admission-free survival: 91% ± 2% no-VR vs 74% ± 7% residual-VR; log-rank p = 0.026). Concomitant valve intervention was not an independent predictor of in-hospital death and morbidity.
Absence of valvular lesion after LVAD implantation was associated with improved midterm hemodynamics and survival in the current study. Aggressive surgical intervention for significant valve disease(s) at the time of LVAD implant may be beneficial to selected patients.
本回顾性单中心研究调查了左心室辅助装置（LVAD）植入后严重瓣膜反流的影响，以及 LVAD 手术时同时进行瓣膜手术的作用。
纳入 2008 年至 2015 年期间接受 LVAD（HeartMate II；雅培，雅培公园，IL）治疗的所有患者。根据手术结束时的瓣膜状况将队列分为两组：无明显瓣膜反流（无 VR）组和存在明显瓣膜反流（残留 VR）组。
共植入 270 例 LVAD。其中，233 例术前存在显著瓣膜疾病，180 例（66.6%）接受了同期瓣膜干预（35 例主动脉瓣，90 例二尖瓣，138 例三尖瓣）。在 LVAD 手术完成时，204 例患者无 VR，66 例患者有残留 VR。两组短期结果相似，但无 VR 组体外循环时间（149 分钟）长于残留 VR 组（132 分钟，p=0.038）。在随访期间，无 VR 组平均肺动脉压（24 毫米汞柱）显著低于残留 VR 组（27 毫米汞柱，p=0.018），肺动脉阻力（无 VR 组 1.8 伍德单位）也显著低于残留 VR 组（2.7 伍德单位，p=0.008）。与残留 VR 组相比，无 VR 组的生存和心力衰竭无入院率在 1 年时显著更高（1 年生存率：72%±3%无 VR 组 vs 55%±6%残留 VR 组；对数秩检验，p=0.026；无入院生存率：91%±2%无 VR 组 vs 74%±7%残留 VR 组；对数秩检验，p=0.026）。同期瓣膜干预不是院内死亡和发病率的独立预测因素。
本研究中，LVAD 植入后无瓣膜病变与中期血液动力学和生存改善相关。在 LVAD 植入时对严重瓣膜疾病进行积极的手术干预可能对选定的患者有益。
