Department of Cardiovascular Medicine, Mayo Clinic Rochester, Minnesota.
Division of Pediatric Cardiology, Mayo Clinic Rochester, Minnesota.
Am J Cardiol. 2019 Dec 1;124(11):1780-1784. doi: 10.1016/j.amjcard.2019.08.035. Epub 2019 Sep 9.
Patients with tetralogy of Fallot (TOF) have abnormal right ventricular (RV) afterload because of residual or recurrent outflow tract obstruction, often with abnormal pulmonary artery (PA) vascular function. The purpose of this study was to determine if RV afterload was independently associated with death and/or heart transplant in patients with TOF. This is a retrospective study of TOF patients that underwent cardiac catheterization for clinical indications at Mayo clinic between 1990 and 2015. Invasively measured RV systolic pressure (RVSP) was used to define RV afterload. To explore clinical utility for echocardiographic estimates of invasive data, correlations between invasive and Doppler-derived indices of RV afterload were examined. Among 266 patients with TOF (age 35 ± 14 years, TOF-pulmonary atresia 117 [44%]), RVSP was 72 ± 28 mm Hg, PA systolic pressure 45 ± 19 mm Hg, mean PA pressure 27 ± 10 mm Hg, pulmonary vascular resistance 4.2 ± 3.1 WU, and PA wedge pressure 14 ± 5 mm Hg. Over a mean follow up of 12.9 years, there were 35 deaths and 4 heart transplants. Invasively measured RVSP (hazard ratio 1.25, 95% confidence interval 1.12 to 1.37; p <0.001) and TOF-pulmonary atresia (hazard ratio 1.18, 95% confidence interval 1.08 to 1.41; p = 0.023) were independent risk factors for death and/or transplant. Doppler-derived RVSP was well-correlated with invasive RVSP (r = 0.92, p <0.001), and was also independently associated with the combined end point. RVSP, a composite measure of RV afterload, is independently prognostic in patients with TOF, and can be reliably assessed using Doppler echocardiography. Further study is required to test whether interventions to reduce RVSP can improve outcomes in patients with TOF.
法洛四联症（TOF）患者由于残余或复发性流出道梗阻而存在异常的右心室（RV）后负荷，常伴有肺动脉（PA）血管功能异常。本研究旨在确定 TOF 患者的 RV 后负荷是否与死亡和/或心脏移植独立相关。这是一项对梅奥诊所 1990 年至 2015 年间因临床指征接受心导管检查的 TOF 患者进行的回顾性研究。使用有创测量的 RV 收缩压（RVSP）来定义 RV 后负荷。为了探讨超声心动图估计有创数据的临床应用价值，研究了 RV 后负荷的有创和多普勒衍生指标之间的相关性。在 266 例 TOF 患者（年龄 35±14 岁，TOF-肺动脉闭锁 117 例[44%]）中，RVSP 为 72±28mmHg，PA 收缩压为 45±19mmHg，平均 PA 压为 27±10mmHg，肺血管阻力为 4.2±3.1WU，PA 楔压为 14±5mmHg。在平均 12.9 年的随访期间，有 35 例死亡和 4 例心脏移植。有创测量的 RVSP（危险比 1.25，95%置信区间 1.12 至 1.37；p<0.001）和 TOF-肺动脉闭锁（危险比 1.18，95%置信区间 1.08 至 1.41；p=0.023）是死亡和/或移植的独立危险因素。多普勒衍生的 RVSP 与有创 RVSP 高度相关（r=0.92，p<0.001），且与复合终点独立相关。RVSP 是 RV 后负荷的综合指标，在 TOF 患者中具有独立的预后价值，并且可以使用多普勒超声心动图可靠地评估。需要进一步研究以测试降低 RVSP 的干预措施是否可以改善 TOF 患者的结局。
