根据左心室射血分数的不同，急性心力衰竭患者右心室功能障碍和肺耦联也不同。
Different right ventricular dysfunction and pulmonary coupling in acute heart failure according to the left ventricular ejection fraction.
机构信息
Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, Le Scotte Hospital University of Siena Italy, Italy.
Department of Medical Biotechnology, University of Siena, Siena, Italy.
出版信息
Prog Cardiovasc Dis. 2023 Nov-Dec;81:89-97. doi: 10.1016/j.pcad.2023.07.008. Epub 2023 Aug 2.
BACKGROUND
Right ventricular (RV) dysfunction and pulmonary uncoupling are two acknowledged features associated with poor outcome, however few data defined RV adaptation across the different left ventricular ejection fraction (EF) cut-off. Additionally, less data are reported in patients with acute heart failure (AHF).
AIMS
The aim of present study was to analyse RV function in AHF patients presenting with either reduced or preserved EF.
METHODS
This is a multi-center observational study including 380 patients affected by AHF: 235 had AHF with reduced EF (AHFrEF) and 145 had AHF with preserved EF (AHFpEF). Pulmonary artery systolic pressure (PASP), tricuspid annular plane systolic excursion (TAPSE), S' wave velocity, and the RV end-diastolic diameter (RVEDD) were measured by echocardiography. TAPSE/PASP and S'/PASP ratios were calculated as non-invasive surrogates of RV-pulmonary arterial coupling.
RESULTS
Factors associated with poor outcome were higher values of PASP (45 [40-55] mmHg vs 40 [35-46] mmHg; p < 0.001), RVEDD (44 [38-47] mm vs 37 [35-42] mm; p < 0.001), lower TAPSE values (17 [15-20] mm vs 20 [18-22] mm; p < 0.001) and S' wave (10 [8-12] cm/s vs 11 [10-13] cm/s; p < 0.001), reduced TAPSE/PASP (0.37 [0.29-0.47] vs 0.50 [0.40-0.60]; p < 0.001) and S'/PASP ratios (0.22 [0.18-0.28] vs 0.28 [0.22-0.34]; p < 0.001). However, the prognostic parameters differed according to the LVEF value: in AHFpEF S'/PASP between 0.22 and 0.29 and > 0.29 demonstrated a protective prognostic value (Respectively HR 0.29 (0.16-0.53), p < 0.001 and HR 0.22 [0.12-0.42], p < 0.001). Conversely, in AHFrEF, TAPSE <16 mm (HR 2.59 [1.67-4.03], p < 0.001), ICV > 21 mm (HR 1.17 [1.17-1.28], p = 0.001) and TAPSE/PASP <0.49 HR 1.92 [1.10-3.37], p = 0.023) were related to adverse outcome.
CONCLUSIONS
RV adaptation and RV pulmonary coupling differ in AHF according to the level of LVEF. S' wave, and S'/PASP are associated with adverse outcome in patients with preserved EF; reduced TAPSE and TAPSE/PASP are better prognostic predictors in patients with reduced EF.
背景
右心室（RV）功能障碍和肺不耦合是与预后不良相关的两个公认特征，但很少有数据定义不同左心室射血分数（EF）截点下的 RV 适应性。此外，在急性心力衰竭（AHF）患者中报告的数据较少。
目的
本研究旨在分析射血分数降低或保留的 AHF 患者的 RV 功能。
方法
这是一项多中心观察性研究，纳入了 380 名患有 AHF 的患者：235 名患者患有射血分数降低的 AHF（AHFrEF），145 名患者患有射血分数保留的 AHF（AHFpEF）。通过超声心动图测量肺动脉收缩压（PASP）、三尖瓣环平面收缩期位移（TAPSE）、S'波速度和右心室舒张末期直径（RVEDD）。计算 TAPSE/PASP 和 S'/PASP 比值作为 RV-肺动脉耦联的无创替代指标。
结果
与不良预后相关的因素包括较高的 PASP 值（45 [40-55] mmHg 与 40 [35-46] mmHg；p<0.001）、RVEDD 值（44 [38-47] mm 与 37 [35-42] mm；p<0.001）、较低的 TAPSE 值（17 [15-20] mm 与 20 [18-22] mm；p<0.001）和 S'波速度（10 [8-12] cm/s 与 11 [10-13] cm/s；p<0.001）、较低的 TAPSE/PASP 比值（0.37 [0.29-0.47] 与 0.50 [0.40-0.60]；p<0.001）和 S'/PASP 比值（0.22 [0.18-0.28] 与 0.28 [0.22-0.34]；p<0.001）。然而，预后参数根据 LVEF 值而有所不同：在 AHFpEF 中，S'/PASP 在 0.22 至 0.29 之间和 >0.29 之间具有保护预后价值（分别 HR 0.29（0.16-0.53），p<0.001 和 HR 0.22 [0.12-0.42]，p<0.001）。相反，在 AHFrEF 中，TAPSE <16 mm（HR 2.59 [1.67-4.03]，p<0.001）、ICV >21 mm（HR 1.17 [1.17-1.28]，p=0.001）和 TAPSE/PASP <0.49 HR 1.92 [1.10-3.37]，p=0.023）与不良预后相关。
结论
根据 LVEF 水平，AHF 中的 RV 适应性和 RV-肺动脉耦联不同。S'波和 S'/PASP 与 EF 保留患者的不良预后相关；在 EF 降低的患者中，降低的 TAPSE 和 TAPSE/PASP 是更好的预后预测指标。
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