基于连续血流左心室辅助装置支持患者血压的结果：机械循环辅助支持机构注册分析。
Outcomes based on blood pressure in patients on continuous flow left ventricular assist device support: An Interagency Registry for Mechanically Assisted Circulatory Support analysis.
机构信息
Henry Ford Hospitals, Detroit, Michigan.
Inova Heart and Vascular Institute, Falls Church, Virginia.
出版信息
J Heart Lung Transplant. 2020 May;39(5):441-453. doi: 10.1016/j.healun.2019.11.016. Epub 2019 Nov 26.
BACKGROUND
An optimal blood pressure (BP) range to mitigate morbidity and mortality on left ventricular assist device (LVAD) support has not been clearly defined.
METHODS
Average Doppler opening pressure, mean arterial pressure (MAP), and/or systolic blood pressure (SBP) were calculated in operative survivors (n = 16,155) of LVAD support in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). BP distributions were used to group patients into low (BP <25th percentile), normal (25-75th percentile), high (75th-95th percentile), and very high (>95th percentile). Associations between BP and adverse events were evaluated using Cox regression (hazard ratio[HR], 95% confidence interval).
RESULTS
The median (25th, 75th) MAP, Doppler, and SBP (mm Hg) during continuous flow LVAD support were 84 (77, 90), 85 (80, 92), and 99 (90, 107) mm Hg, respectively. BP had a bimodal risk association with survival. At 3 years, survival was 58% ± 1.8% in those with low MAP (≤75 mm Hg) vs 70% ± 0.9%, 71% ± 1.5%, and 63% ± 3.0% in the those with normal, high, or very high average MAP, respectively. Patients with chronically low MAP (≤75 mm Hg), Doppler (≤80 mm Hg), and SBP (<90 mm Hg) had 35%-42% higher adjusted hazards of death than patients with normal or high BP (p ≤ 0.0001). Patients with MAP >100 mm Hg, Doppler ≥105 mm Hg, and SBP ≥120 mm Hg had 17%-20% higher adjusted hazards of death than those with normal pressures (p < 0.05). In patients on axial flow LVADs, elevated SBP (HR 1.08 [95% confidence interval, 1.04-1.13] per 10 mm Hg increase) but not MAP correlated with increased incident of stroke.
CONCLUSIONS
In INTERMACS, BP extremes during LVAD support increase the risk for adverse events, supporting a MAP goal >75 mm Hg and <90 mm Hg. Hypotension conferred the highest risk for mortality. Excessive BP control should be avoided, and Doppler opening pressure should not be assumed to represent MAP in all patients.
背景
在左心室辅助装置（LVAD）支持下，减轻发病率和死亡率的最佳血压（BP）范围尚未明确界定。
方法
在机械循环辅助支持的机构间注册（INTERMACS）中，计算 LVAD 支持的手术幸存者（n=16155）的平均多普勒开口压力、平均动脉压（MAP）和/或收缩压（SBP）。使用 BP 分布将患者分为低（BP<第 25 百分位）、正常（第 25-75 百分位）、高（第 75-95 百分位）和非常高（>第 95 百分位）。使用 Cox 回归（风险比[HR]，95%置信区间）评估 BP 与不良事件之间的关联。
结果
连续血流 LVAD 支持期间的中位（25 分位，75 分位）MAP、多普勒和 SBP（mmHg）分别为 84（77，90）、85（80，92）和 99（90，107）mmHg。BP 与生存的风险呈双峰关联。在 3 年时，低 MAP（≤75mmHg）患者的生存率为 58%±1.8%，而 MAP 正常、高或非常高的患者分别为 70%±0.9%、71%±1.5%和 63%±3.0%。MAP（≤75mmHg）、多普勒（≤80mmHg）和 SBP（<90mmHg）持续偏低的患者的调整死亡风险比 MAP 正常或偏高的患者高 35%-42%（p≤0.0001）。MAP>100mmHg、多普勒≥105mmHg 和 SBP≥120mmHg 的患者的调整死亡风险比压力正常的患者高 17%-20%（p<0.05）。在轴流 LVAD 患者中，SBP（每增加 10mmHg 的 HR 为 1.08[95%置信区间，1.04-1.13]）而不是 MAP 与卒中发生率增加相关。
结论
在 INTERMACS 中，LVAD 支持期间的 BP 极端值会增加不良事件的风险，支持 MAP 目标值>75mmHg 和<90mmHg。低血压导致死亡率风险最高。应避免过度的 BP 控制，并且不应假设所有患者的多普勒开口压力都代表 MAP。
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