左心室辅助装置植入术后严重右心衰竭与术中血流动力学和超声心动图测量的关系。
Intraoperative Hemodynamic and Echocardiographic Measurements Associated With Severe Right Ventricular Failure After Left Ventricular Assist Device Implantation.
机构信息
From the Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts.
Tufts Clinical and Translational Science Institute, Tufts University, and Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston Massachusetts.
出版信息
Anesth Analg. 2019 Jan;128(1):25-32. doi: 10.1213/ANE.0000000000003538.
BACKGROUND
Severe right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation increases morbidity and mortality. We investigated the association between intraoperative right heart hemodynamic data, echocardiographic parameters, and severe versus nonsevere RVF.
METHODS
A review of LVAD patients between March 2013 and March 2016 was performed. Severe RVF was defined by the need for a right ventricular mechanical support device, inotropic, and/or inhaled pulmonary vasodilator requirements for >14 days. From a chart review, the right ventricular failure risk score was calculated and right heart hemodynamic data were collected. Pulmonary artery pulsatility index (PAPi) [(pulmonary artery systolic pressure - pulmonary artery diastolic pressure)/central venous pressure (CVP)] was calculated for 2 periods: (1) 30 minutes before cardiopulmonary bypass (CPB) and (2) after chest closure. Echocardiographic data were recorded pre-CPB and post-CPB by a blinded reviewer. Univariate logistic regression models were used to examine the performance of hemodynamic and echocardiographic metrics.
RESULTS
A total of 110 LVAD patients were identified. Twenty-five did not meet criteria for RVF. Of the remaining 85 patients, 28 (33%) met criteria for severe RVF. Hemodynamic factors associated with severe RVF included: higher CVP values after chest closure (18 ± 9 vs 13 ± 5 mm Hg; P = .0008) in addition to lower PAPi pre-CPB (1.2 ± 0.6 vs 1.7 ± 1.0; P = .04) and after chest closure (0.9 ± 0.5 vs 1.5 ± 0.8; P = .0008). Post-CPB echocardiographic findings associated with severe RVF included: larger right atrial diameter major axis (5.4 ± 0.9 vs 4.9 ± 1.0 cm; P = .03), larger right ventricle end-systolic area (22.6 ± 8.4 vs 18.5 ± 7.9 cm; P = .03), lower fractional area of change (20.2 ± 10.8 vs 25.9 ± 12.6; P = .04), and lower tricuspid annular plane systolic excursion (0.9 ± 0.2 vs 1.1 ± 0.3 cm; P = .008). Right ventricular failure risk score was not a significant predictor of severe RVF. Post-chest closure CVP and post-chest closure PAPi discriminated severe from nonsevere RVF better than other variables measured, each with an area under the curve of 0.75 (95% CI, 0.64-0.86).
CONCLUSIONS
Post-chest closure values of CVP and PAPi were significantly associated with severe RVF. Echocardiographic assessment of RV function post-CPB was weakly associated with severe RVF.
背景
左心室辅助装置（LVAD）植入术后严重右心衰竭（RVF）增加发病率和死亡率。我们研究了术中右心血流动力学数据、超声心动图参数与严重与非严重 RVF 之间的相关性。
方法
对 2013 年 3 月至 2016 年 3 月的 LVAD 患者进行了回顾性分析。严重 RVF 定义为需要右心室机械支持装置、正性肌力药和/或吸入性肺血管扩张剂治疗>14 天。通过病历回顾计算右心衰竭风险评分，并收集右心血流动力学数据。计算肺动脉搏动指数（PAPi）[肺动脉收缩压-肺动脉舒张压/中心静脉压（CVP）]在两个时间段的变化：（1）体外循环（CPB）前 30 分钟；（2）CPB 后。由一位盲法观察者在 CPB 前和 CPB 后记录超声心动图数据。使用单变量逻辑回归模型检查血流动力学和超声心动图指标的性能。
结果
共确定了 110 例 LVAD 患者。25 例不符合 RVF 标准。在其余 85 例患者中，28 例（33%）符合严重 RVF 标准。与严重 RVF 相关的血流动力学因素包括：CPB 后 CVP 值较高（18±9 比 13±5mmHg；P=0.0008），CPB 前和 CPB 后 PAPi 较低（1.2±0.6 比 1.7±1.0；P=0.04）。与严重 RVF 相关的术后超声心动图发现包括：右心房最大直径较大（5.4±0.9 比 4.9±1.0cm；P=0.03），右心室收缩末期面积较大（22.6±8.4 比 18.5±7.9cm；P=0.03），右心室收缩期面积变化率较小（20.2±10.8 比 25.9±12.6；P=0.04），三尖瓣环平面收缩期位移较低（0.9±0.2 比 1.1±0.3cm；P=0.008）。右心衰竭风险评分不是严重 RVF 的显著预测因子。CPB 后 CVP 和 CPB 后 PAPi 对严重 RVF 的区分优于其他测量的变量，每个变量的曲线下面积均为 0.75（95%CI，0.64-0.86）。
结论
CPB 后 CVP 和 PAPi 值与严重 RVF 显著相关。CPB 后右心室功能的超声心动图评估与严重 RVF 有弱相关性。
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