Reinhartz O, Farrar D J, Hershon J H, Avery G J, Haeusslein E A, Hill J D
Department of Cardiac Surgery, California Pacific Medical Center, San Francisco 94115, USA.
J Thorac Cardiovasc Surg. 1998 Oct;116(4):633-40. doi: 10.1016/S0022-5223(98)70171-0.
Patient selection is crucial for the success of ventricular assist devices as a bridge to heart transplantation.
The objective of this study was to identify preoperative markers for survival and end-organ recovery in patients having a ventricular assist device.
A retrospective study was performed on 32 severely ill patients with end-stage cardiac failure being mechanically bridged to heart transplantation with the Thoratec Ventricular Assist Device System (Thoratec Laboratories Corporation, Pleasanton, Calif) in a single center between 1984 and 1995. The preoperative cardiac index averaged 1.6 L/min per square meter with a pulmonary capillary wedge pressure of 29 mm Hg. Because of a high incidence of hepatic or renal dysfunction, or both (total bilirubin: 3.5 +/- 6.2 mg/dL; creatinine: 2.0 +/- 1.3 mg/dL), biventricular support was used in most patients (28/32). A total of 30 preoperative and 4 perioperative variables were evaluated for their association with survival and liver recovery.
Nineteen patients (59.4%) survived to transplantation and 13 died. All 19 patients undergoing transplantation were discharged alive with a 1-year survival of 94.4%. All patients without liver recovery died of multiorgan failure. Direct and indirect bilirubin measurements were the only significant predictors for survival to discharge (P = .036, .045); all other factors failed to show significance. As direct bilirubin levels increased (normal range, 3 times normal, and >3 times normal), patient survival decreased (82 %, 56%, and 33 %, respectively). In addition, bilirubin and liver enzyme levels before insertion of the assist device were significantly associated with liver recovery during support with the device.
In our patient population with ventricular assist devices, liver function is the most predictive factor of patient survival in bridging to transplantation.
患者选择对于心室辅助装置作为心脏移植桥梁的成功至关重要。
本研究的目的是确定接受心室辅助装置患者生存和终末器官恢复的术前标志物。
对1984年至1995年期间在单一中心使用Thoratec心室辅助装置系统（Thoratec实验室公司，加利福尼亚州普莱森顿）进行机械性桥接至心脏移植的32例重症终末期心力衰竭患者进行了回顾性研究。术前心脏指数平均为1.6升/分钟每平方米，肺毛细血管楔压为29毫米汞柱。由于肝或肾功能不全或两者发生率高（总胆红素：3.5±6.2毫克/分升；肌酐：2.0±1.3毫克/分升），大多数患者（28/32）使用了双心室支持。共评估了30个术前和4个围手术期变量与生存和肝脏恢复的相关性。
19例患者（59.4%）存活至移植，13例死亡。所有19例接受移植的患者均存活出院，1年生存率为94.4%。所有肝脏未恢复的患者均死于多器官功能衰竭。直接和间接胆红素测量是出院生存的唯一显著预测因素（P = 0.036，0.045）；所有其他因素均无显著性。随着直接胆红素水平升高（正常范围、3倍正常和>3倍正常），患者生存率下降（分别为82%、56%和33%）。此外，辅助装置植入前的胆红素和肝酶水平与装置支持期间的肝脏恢复显著相关。
在我们使用心室辅助装置的患者群体中，肝功能是桥接至移植时患者生存的最具预测性的因素。
