肺毛细血管楔压与心脏再同步化治疗慢性心衰疗效的相关性分析

Association between pulmonary capillary wedge pressure and clinical outcome of cardiac resynchronization therapy in chronic heart failure patients

目的 :探讨右心导管肺毛细血管楔压(pulmonary capillary wedge pressure,PCWP)与心脏再同步化治疗(cardiac resynchronization therapy,CRT)慢性心衰疗效的相关性。方法:入选拟行心脏再同步化治疗的慢性心衰患者,术前1周内进行右心导管检查,测定肺毛细血管楔压;根据CRT术后患者心功能变化分成CRT有反应组与无反应组。术后6个月内左室射血分数(LVEF)提高超过5%,纽约心功能分级(NYHA)降低1级或1级以上者定义为CRT有反应;通过受试者工作曲线分析PCWP对CRT反应性的预测价值。应用Kaplan-Meier生存曲线分析不同水平PCWP患者主要心血管不良事件的差异。结果:35例CRT患者中有反应24例,无反应11例;有反应组PCWP(11.9±7.0)mm Hg,无反应组PCWP(21.7±9.1)mm Hg,两组间差异有统计学意义(P=0.006)。以PCWP 12.0 mm Hg为最佳分界点时,Youden指数最大,预测CRT反应性的敏感度为90.9%,特异度为58.3%。相对于PCWP>12.0 mm Hg组,PCWP≤12.0 mm Hg组CRT术后心功能、左室内径和PCWP更佳。Kaplan-Meier生存曲线表明PCWP≤12.0 mm Hg组患者比PCWP>12.0 mm Hg组患者无主要心血管不良事件的生存时间长,但未达到统计学差异(P=0.079)。结论:术前右心导管检测PCWP对CRT反应性有较好的预测价值。术前PCWP低的患者无主要心血管不良事件的生存时间长。

Objective：To investigate the association between pulmonary capillary wedge pressure（PCWP）and clinical outcome of cardiac resynchronization therapy（CRT）in chronic heart failure patients. Methods：Chronic heart failure patients with an indication for CRT were included. We performed right heart catheterization to measure PCWP in those patients one week before they received a CRT device. Patients were stratified into two groups based on their response to CRT：responders and non-responders. Responders were predefined as patients with improvement of left ventricular ejection fraction（LVEF）by 5% or more and improvement by one or more NYHA functional class during 6-month follow-up. Receiver operating characteristic（ROC）curve was used to assess the efficiency of preoperative PCWP in predicting CRT response. Kaplan-Meier survival curve was applied to assess the efficiency of preoperative PCWP in predicting major adverse cardiac events（MACE）. Results：Of 35 patients included,24 patients were responders,11 patients were non-responders. The mean PCWP was（11.9 ± 7.0）mm Hg and（21.7 ± 9.1）mm Hg,respectively. Non-responders had a significantly higher PCWP（P=0.006）. When at the optimal cutoff point of 12.0 mm Hg,the sensitivity and specificity of preoperative PCWP predicting response to CRT were 90.9% and 58.3%,respectively. Patients with preoperative PCWP 12.0 mm Hg or less have better NYHA functional class、smaller left ventricle and lower PCWP after CRT compared with patients with preoperative PCWP 12.0 mm Hg ormore. Kaplan Meier survival curve demonstrated that compared with patients with preoperative PCWP 12.0 mm Hg or less,patients with preoperative PCWP 12.0 mm Hg or more had a trend towards being shorter MACE-free survival（P =0.079）. Conclusion：Preoperative PCWP is associated with response to CRT. Lower preoperative PCWP may indicate longer MACE-free survival time in CHF patients.