Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston MA (E.W.G., J.I.N.).
Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (E.W.G., K.K.).
Circ Heart Fail. 2022 Apr;15(4):e008613. doi: 10.1161/CIRCHEARTFAILURE.121.008613. Epub 2022 Mar 25.
Elevated right ventricular afterload following continuous-flow left ventricular assist device (CF-LVAD) may contribute to late right heart failure (LRHF). PDE5i (phosphodiesterase-5 inhibitors) are used to treat pulmonary hypertension and right heart dysfunction after CF-LVAD, but their impact on outcomes is uncertain.
We queried Interagency Registry for Mechanically Assisted Circulatory Support from 2012 to 2017 for adults receiving a primary CF-LVAD and surviving ≥30 days from index discharge. Patients receiving early PDE5i (ePDE5i) at 1 month were propensity-matched 1:1 with controls. The primary outcome was the cumulative incidence of LRHF, defined using prevailing Interagency Registry for Mechanically Assisted Circulatory Support criteria; secondary outcomes included all-cause mortality and major bleeding.
Among 9627 CF-LVAD recipients analyzed, 2463 (25.6%) received ePDE5i and 1600 were propensity-matched 1:1 with controls. Before implant, ePDE5i patients had more severe RV dysfunction (13.1% versus 9.6%) and higher pulmonary vascular resistance (2.8±2.7 versus 2.2±2.4 WU), both <0.001, but clinical factors were well-balanced after propensity-matching. In the unmatched cohort, ePDE5i patients had a higher 3-year cumulative incidence of LRHF, mortality, and major bleeding, but these differences were attenuated in the propensity-matched cohort: LRHF 40.8% versus 35.7% (hazard ratio, 1.14 [95% CI, 0.99-1.32]; =0.07); mortality 38.6% versus 35.8% (hazard ratio, 0.99 [95% CI, 0.86-1.15]; =0.93); major bleeding 51.2% versus 46.0% (hazard ratio, 1.12 [95% CI, 0.99-1.27]; =0.06).
Compared with propensity-matched controls, adult CF-LVAD patients receiving ePDE5i had similar rates of LRHF, mortality, and major bleeding. While intrinsic patient risk factors likely account for more adverse outcomes with ePDE5i in the unmatched cohort, there is no obvious benefit of ePDE5i in the LVAD population.
连续流动左心室辅助装置（CF-LVAD）后右心室后负荷升高可能导致晚期右心衰竭（LRHF）。PDE5i（磷酸二酯酶-5 抑制剂）用于治疗 CF-LVAD 后的肺动脉高压和右心功能障碍，但它们对结局的影响尚不确定。
我们从 2012 年至 2017 年查询了机械循环支持机构间注册处，以获取接受主要 CF-LVAD 治疗且出院后存活≥30 天的成人患者。在 1 个月时接受早期 PDE5i（ePDE5i）的患者通过倾向评分匹配以 1:1 的比例与对照组匹配。主要结局是使用现行机械循环支持机构间注册处标准定义的 LRHF 的累积发生率；次要结局包括全因死亡率和主要出血。
在分析的 9627 例 CF-LVAD 接受者中，2463 例（25.6%）接受了 ePDE5i，1600 例与对照组按 1:1 进行倾向评分匹配。在植入前，ePDE5i 患者的 RV 功能障碍更严重（13.1%对 9.6%），肺血管阻力更高（2.8±2.7 对 2.2±2.4 WU），均<0.001，但在进行倾向评分匹配后，临床因素得到了很好的平衡。在未匹配的队列中，ePDE5i 患者的 3 年累积 LRHF、死亡率和主要出血发生率较高，但在匹配的队列中这些差异减弱：LRHF 40.8%对 35.7%（风险比，1.14[95%CI，0.99-1.32]；=0.07）；死亡率 38.6%对 35.8%（风险比，0.99[95%CI，0.86-1.15]；=0.93）；主要出血 51.2%对 46.0%（风险比，1.12[95%CI，0.99-1.27]；=0.06）。
与匹配的对照组相比，接受 ePDE5i 的成年 CF-LVAD 患者的 LRHF、死亡率和主要出血发生率相似。虽然在未匹配的队列中，内在的患者风险因素可能导致 ePDE5i 治疗的更多不良结局，但在 LVAD 人群中，ePDE5i 并没有明显的益处。
