影响缺血性心肌病血运重建后左心室射血分数的多因素分析
|
摘要
目的探讨如何筛选出血运重建后左心室射血分数(LVEF)明显增加的缺血性心肌病(ischaemic cardiomyopathy,ICM)患者。方法回顾性分析我院2010年7月至2015年12月期间,245例行冠状动脉旁路移植术(coronary bypass grafting,CABG)(30%≤LVEF≤40%),其中合并缺血性二尖瓣反流146例(146/245,59.6%),有41例患者因中度以上的缺血性二尖瓣反流而同时行二尖瓣成形术/置换术。围术期死亡13例(12例为CABG+二尖瓣成形术或置换术,1例为单纯行CABG术),余232例随访6个月以上为研究对象,根据术后LVEF是否增加10%分为两组,即LVEF恢复组(A组)124例,LVEF不恢复组(B组)108例。结果单因素分析发现A组术前NT-proBNP值明显高于B组(P=0.036),有心肌梗死病史的比例明显低于B组(P=0.047),而术前仍有心绞痛的比例明显高于B组(P=0.024)。两组之间的二尖瓣反流程度及二尖瓣成形术或置换术比例差异无统计学意义(P=0.199)。A组患者的左心室舒张期末内径(LVEDD)、左心室收缩期末内径(LVESD)、左室舒张期末容积(LVEDV)均明显低于B组(P<0.05)。多因素分析发现LVEDD明显增大、术前无明显心绞痛是ICM(30%≤LVEF≤40%)患者行血运重建后LVEF不能恢复的术前危险因素。以245例患者(包括13例围术期死亡患者)为研究对象,其LVEDD为41～71 mm,发现LVEDD≥60 mm与ICM患者的预后不良有显著关系(χ2=8.63,P=0.003,OR=2.21,95%CI 1.25～3.91)。结论发现LVEDD明显增大、术前无明显心绞痛是ICM(30%≤LVEF≤40%)患者行血运重建后LVEF不能恢复的术前危险因素。LVEDD≥60 mm可以作为ICM(30%≤LVEF≤40%)患者预后不良的术前临床筛选指标之一。
Objective We probed how to predict left ventricular ejection fraction(LVEF) of the ischaemic cardiomyopathy(ICM) patients would be improved apparently after revascularization. Methods Between July 2010 and December 2015, 245 ICM patients(30%≤LVEF≤40%) with coronary bypass grafting(CABG) were retrospectively observed. Among them, 146 patients were accompanied by ischemic mitral regurgitation(IMR)(146/245, 59.6%), and 41 patients underwent mitral valvuloplasty or replacement because of more than moderate IMR. There were 13 patients early death, and other 232 patients who were followed up over 6 months were divided into two groups based on whether or not post-operative LVEF increased by 10%: a LVEF recovered group(group A, 124 patients) and a non-recovered group(group B, 108 patients). Results Preoperative NT-proBNP in the group A was significantly higher than that in the group B(P=0.036). There were less patients with myocardial infarction in the group A than that in the group B(P=0.047), and more with angina pectoris in the group A than that in the group B(P=0.024). There was no significant difference in the extent of mitral regurgitation or mitral surgery between the groups A and B(P>0.05). There were lower left ventricular end-diastolic diameter(LVEDD), left ventricular end-systolic diameter(LVESD) and left ventricular end-diastolic volume(LVEDV) in the group A than those in the group B(P<0.05). Multivariate analysis revealed that preoperative LVEDD dilated apparently and no angina pectoris existed before surgery were independent risk factors for LVEF with no recovery in the ICM patients(30%≤LVEF≤40%) after revascularization. The LVEDD of 245 patients(including 13 early deaths)was 41-71 mm. We found that the ICM patients with LVEDD ≥60 mm were more likely to signify the unfavourable prognosis(χ2=8.63, P=0.003, OR=2.21, 95% confidence interval 1.25 to 3.91). Conclusion Preoperative LVEDD dilated and no angina pectoris before surgery are independent risk factors for LVEF with no recovery in the ICM patients(30%≤LVEF≤40%) after revascularization. LVEDD≥60 mm can be regarded as the preoperative forecasting factors for the unfavourable prognosis in the ICM patients(30%≤LVEF≤40%) after revascularization.
Objective We probed how to predict left ventricular ejection fraction(LVEF) of the ischaemic cardiomyopathy(ICM) patients would be improved apparently after revascularization. Methods Between July 2010 and December 2015, 245 ICM patients(30%≤LVEF≤40%) with coronary bypass grafting(CABG) were retrospectively observed. Among them, 146 patients were accompanied by ischemic mitral regurgitation(IMR)(146/245, 59.6%), and 41 patients underwent mitral valvuloplasty or replacement because of more than moderate IMR. There were 13 patients early death, and other 232 patients who were followed up over 6 months were divided into two groups based on whether or not post-operative LVEF increased by 10%: a LVEF recovered group(group A, 124 patients) and a non-recovered group(group B, 108 patients). Results Preoperative NT-proBNP in the group A was significantly higher than that in the group B(P=0.036). There were less patients with myocardial infarction in the group A than that in the group B(P=0.047), and more with angina pectoris in the group A than that in the group B(P=0.024). There was no significant difference in the extent of mitral regurgitation or mitral surgery between the groups A and B(P>0.05). There were lower left ventricular end-diastolic diameter(LVEDD), left ventricular end-systolic diameter(LVESD) and left ventricular end-diastolic volume(LVEDV) in the group A than those in the group B(P<0.05). Multivariate analysis revealed that preoperative LVEDD dilated apparently and no angina pectoris existed before surgery were independent risk factors for LVEF with no recovery in the ICM patients(30%≤LVEF≤40%) after revascularization. The LVEDD of 245 patients(including 13 early deaths)was 41-71 mm. We found that the ICM patients with LVEDD ≥60 mm were more likely to signify the unfavourable prognosis(χ2=8.63, P=0.003, OR=2.21, 95% confidence interval 1.25 to 3.91). Conclusion Preoperative LVEDD dilated and no angina pectoris before surgery are independent risk factors for LVEF with no recovery in the ICM patients(30%≤LVEF≤40%) after revascularization. LVEDD≥60 mm can be regarded as the preoperative forecasting factors for the unfavourable prognosis in the ICM patients(30%≤LVEF≤40%) after revascularization.
引文
1Felker GM, Shaw LK, O’Connor CM. A standardized definition of ischemic cardiomyopathy for use in clinical research. J Am Coll Cardiol, 2002, 39(2):210-218.
2 Gheorghiade M, Sopko G, De Luca L, et al. Navigating the crossroads of coronary artery disease and heart failure. Circulation,2006, 114(11):1202-1213.
3中华医学会心血管病学分会.中国部分地区1980、1990、2000年慢性心力衰竭住院病例回顾性调查.中华心血管病杂志, 2002,30(8):450-454.
4 Verheyen F, Racz R, Borgers M, et al. Chronic hibernating myocardium in sheep can occur without degenerating events and is reversed after revascularization. Cardiovasc Pathol, 2014, 23(3):160-168.
5Bhat A, Gan GC, Tan TC, et al. Myocardial viability:from proof of concept to clinical practice. Cardiol Res Pract, 2016, 2016:1020818.
6 Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med,2011, 364(17):1607-1616.
7Bonow RO, Maurer G, Lee KL, et al. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med,2011, 364(17):1617-1625.
8 Burns RJ, Gibbons RJ, Yi Q, et al. The relationships of left ventricular ejection fraction, end-systolic volume index and infarct size to six-month mortality after hospital discharge following myocardial infarction treated by thrombolysis. J Am Coll Cardiol,2002, 39(1):30-36.
9Hobbs FDR, Kenkre JE, Roalfe AK. Impact of heart failure and left ventricular systolic dysfunction on quality of life:a cross-sectional study comparing common chronic cardiac and medical disorders and a representative adult population. Eur Heart J, 2002, 23:1867-1876.
10 Borger MA, Alam A, Murphy PM, et al. Chronic ischemic mitral regurgitation:repair, replace or rethink? Ann Thorac Surg, 2006,81(3):1153-1161.
11Bax JJ, Schinkel AFL, Boersma E, et al. Extensive left ventricular remodeling does not allow viable myocardium to improve in left ventricular ejection fraction after revascularization and is associated with worse long-term prognosis. Circulation, 2004,110 (supple 1):II18-II22.
12 La Canna G, Rahimtoola SH, Visioli O, et al. Sensitivity, specificity,and predictive accuracies of non-invasive tests, singly and in combination, for diagnosis of hibernating myocardium. Eur Heart J, 2000, 21(16):1358-1367.
13Pellikka PA, Nagueh SF, Elhendy AA. American Society of Echocardiography recommendations for performance,interpretation, and application of stress echocardiography. J Am Soc Echocardiogr, 2007, 20(9):1021-1041.
14 Schinkel AFL, Valkema R, Geleijnse ML, et al. Single-photon emission computed tomography for assessment of myocardial viability. Euro Intervention, 2010, 6(supple G):G115-G122.
15Anagnostopoulos C, Georgakopoulos A, Pianou N, et al.Assessment of myocardial perfusion and viability by positron emission tomography. Int J Cardiol, 2013, 167(5):1737-1749.
16 Thomson LEJ, Kim RJ, Judd RM. Magneticresonance imaging for the assessment of myocardial viability. J Mag Res Imag, 2004,19(6):771-788.
17Shan K, Constantine G, Sivananthan M, et al. Role of cardiac magnetic resonance imaging in the assessmentof myocardial viability. Circulation, 2004, 109(11):1328-1334.
18 Bax JJ, Poldermans D, Elhendy A, et al. Improvement of left ventricular ejection fraction, heart failure symptoms and prognosis after revascularization in patients with chronic coronary artery disease and viable myocardium detected by dobutamine stress echocardiography. J Am Coll Cardiol, 1999, 34(1):163-169.
19Pasquet A, Williams MJ, Secknus MA, et al. Correlation of preoperative myocardial function, perfusion, and metabolism with postoperative function at rest and stress after bypass surgery in severe left ventricular dysfunction. Am J Cardiol, 1999, 84(1):58-64.
20 Nishimura RA, Otto CM, Bonow RO, et a1. 2014 AHA/ACC guideline for the management of patients with valvular heart disease:A report of the Ameriean College of Cardiology/AmericanHeart Assoeiation Task Force on Practice Guidelines EB/OL. J Am Coll Cardiol, 2014, 148(1):e1-e132.
21Al-Mohammad A, Walton MS. Prevalence of myocardial viability as detected by positron emission tomography in patients with ischemic cardiomyopathy. Circulation, 2000, 102(4):E31.
22 Schinkel AF, Bax JJ, Sozzi FB, et al. Prevalence of myocardial viability assessed by single photon emission computed tomography in patients with chronic ischaemic left ventricular dysfunction.Heart, 2002, 88(2):125-130.
23Shabana A, El-Menyar A. Myocardial viability:what we knew and what is new. Cardiol Res Pract, 2012, 2012:607486.
24 Suleiman M, Khatib R, Agmon Y, et al. Early inflammation and risk of long-term development of heart failure and mortality in survivors of acute myocardial infarction predictive role of Creactive protein. J Am Coll Cardiol, 2006, 47(5):962-968.
25Hellermann JP, Jacobsen SJ, Redfield MM, et al. Heart failure after myocardial infarction:clinical presentation and survival. Eur J Heart Fail, 2005, 7(1):119-125.
26 Szymanski C, Levine RA, Tribouilloy C, et al. Impact of mitral regurgitation on exercise capacity and clinical outcomes in patients with ischemic left ventricular dysfunction. Am J Cardiol, 2011,108(12):1714-1720.
2 Gheorghiade M, Sopko G, De Luca L, et al. Navigating the crossroads of coronary artery disease and heart failure. Circulation,2006, 114(11):1202-1213.
3中华医学会心血管病学分会.中国部分地区1980、1990、2000年慢性心力衰竭住院病例回顾性调查.中华心血管病杂志, 2002,30(8):450-454.
4 Verheyen F, Racz R, Borgers M, et al. Chronic hibernating myocardium in sheep can occur without degenerating events and is reversed after revascularization. Cardiovasc Pathol, 2014, 23(3):160-168.
5Bhat A, Gan GC, Tan TC, et al. Myocardial viability:from proof of concept to clinical practice. Cardiol Res Pract, 2016, 2016:1020818.
6 Velazquez EJ, Lee KL, Deja MA, et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N Engl J Med,2011, 364(17):1607-1616.
7Bonow RO, Maurer G, Lee KL, et al. Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med,2011, 364(17):1617-1625.
8 Burns RJ, Gibbons RJ, Yi Q, et al. The relationships of left ventricular ejection fraction, end-systolic volume index and infarct size to six-month mortality after hospital discharge following myocardial infarction treated by thrombolysis. J Am Coll Cardiol,2002, 39(1):30-36.
9Hobbs FDR, Kenkre JE, Roalfe AK. Impact of heart failure and left ventricular systolic dysfunction on quality of life:a cross-sectional study comparing common chronic cardiac and medical disorders and a representative adult population. Eur Heart J, 2002, 23:1867-1876.
10 Borger MA, Alam A, Murphy PM, et al. Chronic ischemic mitral regurgitation:repair, replace or rethink? Ann Thorac Surg, 2006,81(3):1153-1161.
11Bax JJ, Schinkel AFL, Boersma E, et al. Extensive left ventricular remodeling does not allow viable myocardium to improve in left ventricular ejection fraction after revascularization and is associated with worse long-term prognosis. Circulation, 2004,110 (supple 1):II18-II22.
12 La Canna G, Rahimtoola SH, Visioli O, et al. Sensitivity, specificity,and predictive accuracies of non-invasive tests, singly and in combination, for diagnosis of hibernating myocardium. Eur Heart J, 2000, 21(16):1358-1367.
13Pellikka PA, Nagueh SF, Elhendy AA. American Society of Echocardiography recommendations for performance,interpretation, and application of stress echocardiography. J Am Soc Echocardiogr, 2007, 20(9):1021-1041.
14 Schinkel AFL, Valkema R, Geleijnse ML, et al. Single-photon emission computed tomography for assessment of myocardial viability. Euro Intervention, 2010, 6(supple G):G115-G122.
15Anagnostopoulos C, Georgakopoulos A, Pianou N, et al.Assessment of myocardial perfusion and viability by positron emission tomography. Int J Cardiol, 2013, 167(5):1737-1749.
16 Thomson LEJ, Kim RJ, Judd RM. Magneticresonance imaging for the assessment of myocardial viability. J Mag Res Imag, 2004,19(6):771-788.
17Shan K, Constantine G, Sivananthan M, et al. Role of cardiac magnetic resonance imaging in the assessmentof myocardial viability. Circulation, 2004, 109(11):1328-1334.
18 Bax JJ, Poldermans D, Elhendy A, et al. Improvement of left ventricular ejection fraction, heart failure symptoms and prognosis after revascularization in patients with chronic coronary artery disease and viable myocardium detected by dobutamine stress echocardiography. J Am Coll Cardiol, 1999, 34(1):163-169.
19Pasquet A, Williams MJ, Secknus MA, et al. Correlation of preoperative myocardial function, perfusion, and metabolism with postoperative function at rest and stress after bypass surgery in severe left ventricular dysfunction. Am J Cardiol, 1999, 84(1):58-64.
20 Nishimura RA, Otto CM, Bonow RO, et a1. 2014 AHA/ACC guideline for the management of patients with valvular heart disease:A report of the Ameriean College of Cardiology/AmericanHeart Assoeiation Task Force on Practice Guidelines EB/OL. J Am Coll Cardiol, 2014, 148(1):e1-e132.
21Al-Mohammad A, Walton MS. Prevalence of myocardial viability as detected by positron emission tomography in patients with ischemic cardiomyopathy. Circulation, 2000, 102(4):E31.
22 Schinkel AF, Bax JJ, Sozzi FB, et al. Prevalence of myocardial viability assessed by single photon emission computed tomography in patients with chronic ischaemic left ventricular dysfunction.Heart, 2002, 88(2):125-130.
23Shabana A, El-Menyar A. Myocardial viability:what we knew and what is new. Cardiol Res Pract, 2012, 2012:607486.
24 Suleiman M, Khatib R, Agmon Y, et al. Early inflammation and risk of long-term development of heart failure and mortality in survivors of acute myocardial infarction predictive role of Creactive protein. J Am Coll Cardiol, 2006, 47(5):962-968.
25Hellermann JP, Jacobsen SJ, Redfield MM, et al. Heart failure after myocardial infarction:clinical presentation and survival. Eur J Heart Fail, 2005, 7(1):119-125.
26 Szymanski C, Levine RA, Tribouilloy C, et al. Impact of mitral regurgitation on exercise capacity and clinical outcomes in patients with ischemic left ventricular dysfunction. Am J Cardiol, 2011,108(12):1714-1720.