肺动脉收缩压对心脏再同步化治疗患者术后超反应及预后的影响

Effect of pulmonary artery systolic pressure on super-response and prognosis in patients after cardiac resynchronization therapy

目的评估术前肺动脉收缩压(pulmonary artery systolic pressure,PASP)对心脏再同步化治疗(cardiac resynchronization therapy,CRT)患者术后心功能、左心室重构和预后的影响。方法回顾性分析2014年6月至2017年12月在本院进行CRT的73例患者资料,根据超声心动图估测的术前PASP分成两组:肺动脉高压组(PASP≥50 mm Hg) 27例和非肺动脉高压组(PASP<50 mm Hg) 46例。CRT术后6个月评估心功能,复查心电图和超声心动图,并比较两组之间的差异,采用ROC曲线评估术前PASP对CRT超反应的预测价值,采用Kaplan-Meier法进行生存分析,采用Cox回归模型分析影响长期预后的危险因素。结果 73例患者中男性52例,女性21例,年龄(60.32±9.78)岁。CRT术后肺动脉高压组纽约心脏协会(New York Heart Association,NYHA)心功能分级、左室射血分数(left ventricular ejection fraction,LVEF)和左心室舒张末期内径(left ventricular end-diastolic dimension,LVEDD)改善程度较非肺动脉高压组差(P<0.05),肺动脉高压组LVEDD较术前无改善(P>0.05)。术前PASP≤35 mm Hg对CRT超反应有一定的预测价值(AUC:0.709,95%CI:0.575～0.843,P<0.05)。肺动脉高压组复合终点事件(心衰再入院或全因死亡)发生率高于非肺动脉高压组(P<0.05),肺动脉高压(HR:3.64,95%CI:1.25～10.61,P<0.05)、左心房内径(left atrial dimension,LAD)(HR:1.10,95%CI:1.01～1.20,P<0.05)是影响CRT术后患者预后的独立危险因素。结论术前PASP升高的患者CRT术后心功能改善、左室重构逆转的效果和临床预后较术前PASP正常的患者差,术前PASP≤35 mm Hg对CRT超反应有预测价值,肺动脉高压、LAD是CRT术后患者临床预后的独立危险因素。

Objective To evaluate the impact of baseline pulmonary artery systolic pressure(PASP)on cardiac function,left ventricle reverse remodeling and clinical outcomes in patients receiving cardiac resynchronization therapy(CRT).Methods A total of 73 patients undergoing CRT in our hospital between June,2014 and December,2017 were enrolled in this retrospective analysis.According to baseline PASP estimated by echocardiography,the patients were divided into pulmonary artery hypertension(PAH) group(PASP≥ 50 mm Hg;n=27) and non-pulmonary artery hypertension(NPAH) group(PASP<50 mm Hg;n=46) for comparison of cardiac function,electrocardiogram and echocardiogram at 6 months after CRT.A receiver operator characteristic(ROC) curve was used to evaluate the value of baseline PASP in predicting super-response to CRT.The combined endpoints including all-cause mortality and rehospitalization for heart failure were compared between the 2 groups using Kaplan-Meier analysis.Cox regression models were constructed to analyze the risk factors for long-term prognosis of the patients.Results The 73 patients enrolled included 52 male and 21 female patients at a mean age of 60.32±9.78 years.At 6 months after the operation,the patients in PAH group had significantly poorer improvements in cardiac functions,left ventricular ejection fraction(LVEF) and left ventricular end-diastolic diameter(LVEDD) than those in NPAH group(P<0.05),and showed no obvious improvement in LVEDD(P>0.05).ROC curve analysis showed that PASP ≤35 mm Hg was capable of predicting super-response to CRT with an area under the ROC curve of 0.709(95% CI:0.575-0.843,P<0.05).The patients in PAH group had a higher incidence of combined endpoints than those in NPAH group.PAH(HR=3.64,95% CI:1.25-10.61,P<0.05) and left atrial diameter(HR=1.10,95% CI:1.01-1.20,P<0.05) were independent predictors for the clinical outcomes of the patients.Conclusion Patients with elevated baseline PASP have poorer improvements in cardiac function,left ventricle reverse remodeling and prognosis following CRT than those with normal PASP.A baseline PASP ≤35 mm Hg is predictive of super-response to CRT,and PAH and left atrial diameter are independent predictors of the clinical outcomes following CRT.