Levine T B, Levine A B, Goldberg D, Narins B, Goldstein S, Lesch M
Department of Medicine, Henry Ford Hospital, Detroit, Mich. 48202, USA.
J Heart Lung Transplant. 1996 Mar;15(3):297-303.
Long waiting list periods for heart transplantation have led to clinical improvements for some patients resulting in their removal from the waiting list. This study sought to determine what characteristics differentiated those patients with a good clinical outcome from those who continued to need a transplant.
The initial and final serial (every 3 months) right heart catheterization data of 60 patients awaiting transplantation were retrospectively analyzed, and the patients were divided into two groups: group A, patients who were taken off the list in follow-up because of improvement (n = 18 of 60), and group B who continued to require transplantation or died (n = 42 of 60).
For Group A, there were significant declines in right atrial pressure (9 +/- 4 to 4 +/- 3 mm Hg, initial versus final, p = 0.001), systolic pulmonary arterial pressure (51 +/- 17 to 34 +/- 6 mm Hg, p = 0.0001), with an increase in electron in ejection fraction (20% +/- 4% to 34% +/- 10%, p = 0.005). The change in cardiac output and norepinephrine level was not statistically significant. For Group B, there were no changes in the initial and final values of right atrial pressure, systolic pulmonary arterial pressure, pulmonary capillary wedge pressure, or norepinephrine levels. A significant rise in ejection fraction from 17% +/- 22% +/- 8%, p = 0.003 did occur. The majority of patients in group A (12 of 18) had idiopathic dilated cardiomyopathy. In contrast, an ischemic etiology was found in the majority of group B patients (25 of 42).
This study shows that transplant waiting list outcome cannot be predicted from a patient's initial hemodynamic or neurohormonal presentation. Rather, those patients capable of reversing their hemodynamic derangements with therapy over time are most likely to sustain a favorable clinical outcome. It appears that patients with idiopathic rather than ischemic cardiomyopathy respond more favorably to medical interventions with improved prognosis.
心脏移植的漫长等待名单期已使部分患者的临床状况得到改善，从而不再需要等待移植。本研究旨在确定哪些特征可区分临床结局良好的患者与仍需移植的患者。
回顾性分析60例等待移植患者的初始及连续（每3个月一次）右心导管检查数据，将患者分为两组：A组，随访期间因病情改善而被从等待名单中剔除的患者（60例中的18例）；B组，继续需要移植或死亡的患者（60例中的42例）。
对于A组，右心房压力显著下降（初始值9±4 mmHg，最终值4±3 mmHg，p = 0.001），收缩期肺动脉压下降（51±17 mmHg至34±6 mmHg，p = 0.0001），射血分数增加（20%±4%至34%±10%，p = 0.005）。心输出量和去甲肾上腺素水平的变化无统计学意义。对于B组，右心房压力、收缩期肺动脉压、肺毛细血管楔压或去甲肾上腺素水平的初始值和最终值均无变化。射血分数从17%±上升至22%±8%，p = 0.003，有显著升高。A组中的大多数患者（18例中的12例）患有特发性扩张型心肌病。相比之下，B组中的大多数患者（42例中的25例）病因是缺血性的。
本研究表明，无法根据患者的初始血流动力学或神经激素表现来预测移植等待名单的结局。相反，那些能够随着时间推移通过治疗逆转血流动力学紊乱的患者最有可能获得良好的临床结局。似乎特发性心肌病患者而非缺血性心肌病患者对医学干预的反应更佳，预后更好。
