Department of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minn.
J Thorac Cardiovasc Surg. 2018 Oct;156(4):1530-1540.e2. doi: 10.1016/j.jtcvs.2018.04.130. Epub 2018 Jun 18.
Despite suggestions that severe left ventricle dysfunction may warrant selection of durable mechanical circulatory support over conventional surgery, comparative studies are lacking due to incomplete characterization of patients at highest risk after conventional surgery. We sought to define subsets of patients with severe left ventricle dysfunction who are at greatest mortality risk following conventional cardiac surgery.
We studied 892 patients aged ≥ 18 years who underwent conventional coronary or valve surgery from 1993 to 2014, with preoperative ejection fraction ≤ 25%. Exclusions were transcatheter interventions, major concomitant procedures, active endocarditis, and prior/concurrent durable mechanical circulatory support use. Logistic and Cox regression identified determinants of early and late mortality.
Median age was 70 years (interquartile range, 62-76 years), 46% (n = 411) had New York Heart Association (NYHA) functional class IV symptoms, and 16% (n = 142) had undergone prior surgery. Operative mortality was 7.5%. NYHA functional class IV (odds ratio [OR], 1.88; P = .033), prior cardiac surgery (OR, 2.13; P = .017), peripheral vascular disease (OR, 2.55; P = .001), emergency status (OR, 2.68; P = .024), and intra-aortic balloon pump use (OR, 4.95; P < .001) independently predicted operative death. Risk imparted by presence of both NYHA functional class IV symptoms and prior surgery was additive, with a 4-fold increase in early mortality risk (OR, 3.95; P = .003). Prior surgery increased the hazard of late death by 60% (P < .001). In patients without prior surgery, late mortality was greatest in those aged ≥ 70 years (hazard ratio, 1.86; P < .001), especially if NYHA functional class IV symptoms were concurrently present (hazard ratio, 2.25; P < .001). Surgery type (coronary artery bypass graft surgery, aortic valve surgery, or mitral valve surgery) did not predict long-term outcome.
In patients referred for conventional surgery with an ejection fraction ≤ 25%, prior cardiac surgery, and/or NYHA functional class IV symptoms-particularly in those aged ≥ 70 years-confer significant and sustained survival disadvantages. Such high-risk subsets may benefit from durable mechanical circulatory support consideration.
尽管有研究表明严重左心室功能障碍可能需要选择耐用的机械循环支持而非传统手术，但由于对传统手术后风险最高的患者的特征描述不完整，因此缺乏相关的比较研究。我们旨在确定接受传统心脏手术后死亡率最高的严重左心室功能障碍患者亚组。
我们研究了 892 名年龄≥18 岁的患者，这些患者在 1993 年至 2014 年间接受了传统的冠状动脉或瓣膜手术，术前射血分数≤25%。排除标准为经导管介入治疗、主要合并手术、活动性心内膜炎以及先前/同期使用耐用的机械循环支持。Logistic 和 Cox 回归确定了早期和晚期死亡率的决定因素。
中位年龄为 70 岁（四分位距，62-76 岁），46%（n=411）有纽约心脏协会（NYHA）功能分级 IV 级症状，16%（n=142）有既往手术史。手术死亡率为 7.5%。NYHA 功能分级 IV 级（比值比[OR]，1.88；P=0.033）、既往心脏手术史（OR，2.13；P=0.017）、外周血管疾病（OR，2.55；P=0.001）、紧急状态（OR，2.68；P=0.024）和主动脉内球囊泵使用（OR，4.95；P<0.001）独立预测手术死亡。同时存在 NYHA 功能分级 IV 级症状和既往手术史的患者的风险是相加的，早期死亡率风险增加 4 倍（OR，3.95；P=0.003）。无既往手术史的患者中，年龄≥70 岁的患者晚期死亡率最高（风险比，1.86；P<0.001），尤其是同时存在 NYHA 功能分级 IV 级症状的患者（风险比，2.25；P<0.001）。手术类型（冠状动脉旁路移植术、主动脉瓣手术或二尖瓣手术）并不预测长期结果。
在因射血分数≤25%而接受传统手术的患者中，存在既往心脏手术和/或 NYHA 功能分级 IV 级症状，特别是年龄≥70 岁的患者，生存劣势显著且持续存在。这些高危亚组可能受益于耐用的机械循环支持考虑。
