Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York.
Department of Internal Medicine, Division of Cardiovascular Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York.
Ann Thorac Surg. 2019 Aug;108(2):508-516. doi: 10.1016/j.athoracsur.2019.01.063. Epub 2019 Mar 7.
Continuous-flow left ventricular assist devices have revolutionized the management of advanced heart failure. Device complications continue to limit survival, but enhanced management strategies have shown promise. This study compared outcomes for HeartMate II recipients before and after implementation of a multidisciplinary continuous support heart team (HTMCS) strategy.
Between January 2012 and December 2016, 124 consecutive patients underwent primary HeartMate II implantation at our institution. In January 2015, we instituted a HTMCS approach consisting of (1) daily simultaneous cardiology/cardiac surgery/critical care/pharmacy/coordinator rounds, (2) pharmacist-directed anticoagulation, (3) speed optimization echocardiogram before discharge, (4) comprehensive device thrombosis screening and early intervention, (5) blood pressure clinic with pulsatility-adjusted goals, (6) early follow-up after discharge and individual long-term coordinator/cardiologist assignment, and (7) systematic basic/advanced/expert training and credentialing of ancillary in-hospital providers. All patients completed 1-year of follow-up.
Demographic characteristics for pre-HTMCS (n = 71) and HTMCS (n = 53) groups, including age (55.8 ± 12.1 versus 52.5 ± 14.1 years, p = not significant), percentage of men (77.5% versus 71.7%, p = not significant), and Interagency Registry for Mechanically Assisted Circulatory Support class 3 (84.5% versus 83.0%, p = not significant), were comparable. One-year survival was 74.6% versus 100% for the pre-HTMCS and HTMCS groups, respectively (p = 0.0002). One-year survival free of serious adverse events (reoperation to replace device or disabling stroke) was 70.4% versus 84.9% for the pre-HTMCS and HTMCS groups, respectively (p = 0.059). Event per patient-year rates for disabling stroke (0.15 versus 0, p = 0.019), gastrointestinal bleeding (0.87 versus 0.51, p = 0.11), and driveline infection (0.24 versus 0.10, p = 0.18) were lower for the HTMCS group, whereas pump thrombosis requiring device exchange was higher (0.09 versus 0.18, p = 0.14).
Implementing a comprehensive multidisciplinary approach substantially improved outcomes for recipients of continuous-flow left ventricular assist devices.
连续流动左心室辅助设备彻底改变了晚期心力衰竭的治疗方式。设备相关并发症仍然限制着患者的生存，但强化管理策略显示出了希望。本研究比较了我院实施多学科连续支持心脏团队（HTMCS）策略前后 HeartMate II 接受者的结果。
2012 年 1 月至 2016 年 12 月，我院连续收治了 124 例初次植入 HeartMate II 的患者。2015 年 1 月，我们实施了 HTMCS 策略，包括（1）心内科/心外科/重症监护室/药剂科/协调员每天同时查房，（2）药剂师指导抗凝，（3）出院前进行优化的超声心动图检查，（4）全面的设备血栓筛查和早期干预，（5）根据脉压调整目标的血压诊所，（6）出院后早期随访和个人长期协调员/心脏病专家的分配，以及（7）系统的基础/高级/专家培训和医院内辅助人员的认证。所有患者均完成了 1 年的随访。
HTMCS 组（n=53）和 HTMCS 组（n=71）的患者人口统计学特征相似，包括年龄（55.8±12.1 岁 vs 52.5±14.1 岁，p=无显著差异）、男性比例（77.5% vs 71.7%，p=无显著差异）和 Interagency Registry for Mechanically Assisted Circulatory Support 分级 3（84.5% vs 83.0%，p=无显著差异）。HTMCS 组和 HTMCS 组的 1 年生存率分别为 74.6%和 100%（p=0.0002）。HTMCS 组和 HTMCS 组的 1 年严重不良事件（更换设备或致残性中风的再手术）发生率分别为 70.4%和 84.9%（p=0.059）。HTMCS 组患者的致残性中风（0.15 比 0，p=0.019）、胃肠道出血（0.87 比 0.51，p=0.11）和驱动线感染（0.24 比 0.10，p=0.18）的事件发生率较低，而需要更换设备的泵血栓发生率较高（0.09 比 0.18，p=0.14）。
实施全面的多学科方法可显著改善连续流动左心室辅助设备接受者的预后。
