Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich.
Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich.
J Thorac Cardiovasc Surg. 2019 May;157(5):1851-1860.e1. doi: 10.1016/j.jtcvs.2018.11.099. Epub 2018 Dec 11.
To investigate whether preoperative echocardiography findings determine postoperative continuous-flow left ventricular assist device outcomes.
From January 2003 to June 2017, 490 patients received a durable, continuous-flow left ventricular assist device. Two-step clustering of parameters including heart rate and preoperative echocardiographic findings (ie, left ventricular [LV] ejection fraction, right ventricular [RV] function, aortic insufficiency, mitral regurgitation [MR], tricuspid regurgitation [TR]) was performed and identified 5 distinct clusters associated with LV failure: group 1: moderate right ventricular dysfunction (RVD), severe MR and mild TR (n = 110); group 2: severe RVD, severe MR and TR (n = 64); group 3: moderate RVD and severe aortic insufficiency (n = 16); group 4: mild RVD and mild valvular pathology (n = 163); and group 5: moderate-severe RVD and mild valvular pathology (n = 137). Silhouette measure of cohesion and separation demonstrated satisfactory separation at 0.6.
Group 2 had the greatest Interagency Registry for Mechanically Assisted Circulatory Support Level 1 (25%, P = .010), preoperative right atrial pressure (11 ± 5 mm Hg, P < .001), incidence of postoperative right ventricular failure (RVF; 20%, P = .001), delayed closure of the sternum (61%, P = .002), postoperative permanent dialysis (6%, P = .04), rate of tricuspid valve repair (n = 52; 81%, P < .001), and lowest RV stroke work index (489 ± 228 cc mm Hg/m/beat, P < .001). RVF in groups 1, 3, 4, and 5 was 6%, 0%, 4%, and 9%, respectively. No differences in incidence of heart transplantation (P = .400) or survival (P = .535) were found. Severe TR predicted RVF in those with moderate-severe preoperative RVD (P = .001, odds ratio 3.9).
Clustering demonstrated the importance of preoperative TR in predicting RVF. Combined severe LV and RV failure with severe MR and TR portends the worse prognosis.
探讨术前超声心动图检查结果是否决定术后持续血流左心室辅助装置的结局。
2003 年 1 月至 2017 年 6 月，490 例患者接受了耐久性、持续血流左心室辅助装置治疗。对心率和术前超声心动图检查结果（即左心室 [LV] 射血分数、右心室 [RV] 功能、主动脉瓣关闭不全、二尖瓣反流 [MR]、三尖瓣反流 [TR]）进行两步聚类，并确定与 LV 衰竭相关的 5 个不同的簇：组 1：中度 RV 功能障碍（RVD），严重 MR 和轻度 TR（n=110）；组 2：严重 RVD，严重 MR 和 TR（n=64）；组 3：中度 RVD 和严重主动脉瓣关闭不全（n=16）；组 4：轻度 RVD 和轻度瓣膜病变（n=163）；组 5：中度-重度 RVD 和轻度瓣膜病变（n=137）。0.6 处的凝聚和分离的轮廓度量显示出令人满意的分离。
组 2 的 Interagency Registry for Mechanically Assisted Circulatory Support 级别 1 发生率最高（25%，P=0.010），术前右心房压（11±5mmHg，P<0.001），术后 RVF 发生率（20%，P=0.001），胸骨延迟闭合（61%，P=0.002），术后永久性透析（6%，P=0.04），三尖瓣修复术（n=52；81%，P<0.001）和最低 RV 每搏功指数（489±228ccmmHg/m/beat，P<0.001）。组 1、3、4 和 5 的 RVF 发生率分别为 6%、0%、4%和 9%。心脏移植（P=0.400）和存活率（P=0.535）无差异。术前严重 TR 预测中重度术前 RVD 患者的 RVF（P=0.001，优势比 3.9）。
聚类显示术前 TR 在预测 RVF 中的重要性。LV 和 RV 严重衰竭伴严重 MR 和 TR 预示预后更差。
