Capomolla S, Pozzoli M, Opasich C, Febo O, Riccardi G, Salvucci F, Maestri R, Sisti M, Cobelli F, Tavazzi L
Salvatore Maugeri Foundation, Institute of Medical Care and Research Montescano, Pavia, Italy.
Am Heart J. 1997 Dec;134(6):1089-98. doi: 10.1016/s0002-8703(97)70030-9.
In patients with severe heart failure additional therapeutic support with intravenous inotropic or vasodilator drugs is frequently used in the attempt to obtain hemodynamic control. The nature and extent to which diastolic filling, atrial function, and mitral regurgitation are modified by these drugs have not been fully explored. The aim of this study was to compare the acute adaptations of the left ventricular performance, left atrial function, and mitral regurgitation that accompanied hemodynamic improvement during intravenous dobutamine and nitroprusside infusions in patients with severe chronic heart failure.
Forty consecutive patients with severe heart failure were evaluated by simultaneous echo-Doppler and hemodynamic investigations at baseline and during nitroprusside and dobutamine administration. Mitral flow velocity variables, left atrial and ventricular volumes, left atrial reservoir, conduit and pump volumes, and mitral regurgitation jet area were compared by analysis of variance for repeated measurements.
Nitroprusside increased cardiac output (2.1 +/- .5 vs 2.6 +/- .5 L/min/m2, p < 0.004), reduced left ventricular filling pressure (25 +/- 6 vs 14 +/- 4 mm Hg, p < 0.0001), and improved left atrial pump volume (19 +/- 3 vs 26 +/- 12 ml, p < 0.02) without variations in left atrial reservoir and conduit volume. The restoration of preload reserve and improvement of the atrial contribution to left ventricular diastolic filling were demonstrated by the Doppler mitral flow pattern, which moved from a restrictive to a normal pattern. Furthermore mitral regurgitation decreased in all patients (9 +/- 4.6 vs 4.6 +/- 3.4 cm2, p < 0.0001). Dobutamine increased cardiac output (2.1 +/- .5 vs 2.8 +/- .6 L/min/m2), but the effects on pulmonary wedge pressure and mitral regurgitation were variable and unpredictable. Left atrial reservoir and conduit volumes increased, whereas left atrial pump volume did not change (19 +/- 13 vs 22 +/- 14 ml, p = NS). Furthermore Doppler mitral flow showed a persistent restrictive pattern.
In patients with advanced congestive heart failure both nitroprusside and dobutamine improve cardiac output, with different adaptations of left ventricular performance and left atrial function. Nitroprusside seems to restore both atrial and ventricular pump function better. Careful echo-Doppler monitoring during drug infusion provides information relevant to the clinical treatment of individual patients.
在重度心力衰竭患者中，经常使用静脉注射正性肌力药或血管扩张药进行额外的治疗支持，以试图实现血流动力学控制。这些药物对舒张期充盈、心房功能和二尖瓣反流的改变性质及程度尚未得到充分研究。本研究的目的是比较重度慢性心力衰竭患者在静脉输注多巴酚丁胺和硝普钠期间，伴随血流动力学改善的左心室功能、左心房功能和二尖瓣反流的急性适应性变化。
连续40例重度心力衰竭患者在基线时以及硝普钠和多巴酚丁胺给药期间，通过同步超声多普勒和血流动力学检查进行评估。通过重复测量的方差分析比较二尖瓣血流速度变量、左心房和心室容积、左心房储存、管道和泵血容积以及二尖瓣反流束面积。
硝普钠增加心输出量（2.1±0.5 vs 2.6±0.5L/min/m²，p<0.004），降低左心室充盈压（25±6 vs 14±4mmHg，p<0.0001），并改善左心房泵血容积（19±3 vs 26±12ml，p<0.02），而左心房储存和管道容积无变化。二尖瓣血流多普勒模式从限制性模式转变为正常模式，证明了前负荷储备的恢复以及心房对左心室舒张期充盈贡献的改善。此外，所有患者的二尖瓣反流均减少（9±4.6 vs 4.6±3.4cm²，p<0.0001）。多巴酚丁胺增加心输出量（2.1±0.5 vs 2.8±0.6L/min/m²），但对肺楔压和二尖瓣反流的影响多变且不可预测。左心房储存和管道容积增加，而左心房泵血容积未改变（19±13 vs 22±14ml，p=无显著性差异）。此外，二尖瓣血流多普勒显示持续的限制性模式。
在晚期充血性心力衰竭患者中，硝普钠和多巴酚丁胺均可改善心输出量，但左心室功能和左心房功能的适应性变化不同。硝普钠似乎能更好地恢复心房和心室的泵血功能。药物输注期间仔细的超声多普勒监测可为个体患者的临床治疗提供相关信息。
