冠状动脉侧支循环对冠状动脉慢性闭塞病变伴心力衰竭患者介入治疗后左心功能的影响

Effects of coronary collateralization on left ventricular functional recovery after successful recanalization of chronic total occlusion in heart failure patients with reduced ejection fraction

目的分析冠状动脉侧支形成状态对冠状动脉慢性完全闭塞(CTO)病变伴左心室射血分数(LVEF)降低的心力衰竭患者经皮冠状动脉介入治疗(PCI)成功后左心功能的影响。方法选择2015年1月至2020年9月上海交通大学医学院附属瑞金医院PCI数据库中术前LVEF≤40%、至少1支主要冠状动脉存在CTO病变并成功行PCI的患者。根据Rentrop分级,将患者分为侧支形成不良组(0级和1级)和侧支形成良好组(2级和3级)。收集两组的术前基线临床资料,并比较CTO-PCI术前及术后12个月时超声心动图测定的左心室功能和结构变化。结果成功CTO-PCI术12个月后,所有患者的平均LVEF较基线显著增高[(42.09±9.87)%比(32.43±4.79)%,P<0.001],而左心室舒张末期容积指数(EDVI)[(182.60±49.47)ml/m^(2)比(196.10±49.39)ml/m^(2),P<0.001]和左心室收缩末期容积指数(ESVI)[(105.13±44.02)ml/m^(2)比(127.68±38.58)ml/m^(2),P<0.001]均较基线下降,差异均有统计学意义。与侧支形成不良组相比,侧支形成良好组LVEF恢复程度更高[ΔLVEF:(11.75±8.24)%比(7.41±12.10)%,P=0.003],而两组EDVI和ESVI的下降比较,差异均无统计学意义(均P>0.05)。进一步亚组分析发现,在非糖尿病患者中,侧支形成良好组较侧支形成不良组LVEF恢复更好[ΔLVEF:(13.42±8.57)%比(9.49±12.61)%,P=0.021];而在糖尿病患者中,侧支形成良好组较侧支形成不良组则无显著恢复[ΔLVEF:(9.25±7.18)%比(3.95±10.59)%,P=0.110]。全变量校正模型显示,侧支形成良好的非糖尿病患者CTO-PCI后LVEF恢复的概率是侧支形成不良患者的3.989倍(95%CI 1.071~16.523,P=0.044),差异有统计学意义。结论对于LVEF降低的心力衰竭患者,成功的CTO-PCI可明显改善左心室收缩功能,促进左心室逆重构。良好的侧支形成有利于CTOPCI后左心功能的恢复,且这一现象在非糖尿病患者中更为明显。

Objective To investigate the changes in left ventricular ejection function(LVEF)after successful recanalization of chronic total occlusion(CTO)in patients with heart failure with reduced ejection fraction.Methods A total of 116 heart failure patients with LVEF≤40%and at least one CTO lesion which was successfully treated with percutaneous coronary intervention(PCI)were recruited from the PCI Database of Shanghai Ruijin Hospital between January 2015 and September 2020.The status of coronary collaterals supplying to the distal part of CTO was graded according to Rentrop classification:Rentrop 0 or 1 was considered as poor collaterals,whereas Rentrop 2 or 3 was considered as good collaterals.Baseline clinical characteristics and echocardiographic data were collected before and 12 months after the PCI procedure for assessing left ventricular systolic function and remodeling changes.Results Overall,the mean LVEF was increased[(42.09±9.87)%vs.(32.43±4.79)%,P<0.001]and was associated with a high proportion of ventricular reverse remodeling at 12-month follow-up post successful CTO-PCI.Compared with patients with poor collaterals,those with good collaterals had a greater increase in LVEF after CTO-PCI[ΔLVEF:(11.75±8.24)%vs.(7.41±12.10)%,P=0.003],which was more obvious in non-diabetic patients than in diabetics[ΔLVEF:(13.42±8.57)%vs.(9.49±12.61)%,P=0.021].Logistic regression analysis revealed that after adjustment for multiple confounding variables,good collateralization remained an independent predictor for left ventricular functional recovery after CTO-PCI in non-diabetic patients(OR 3.989,95%CI 1.071—16.523,P=0.044).Conclusions In heart failure patients with reduced ejection fraction,successful CTO-PCI improves left ventricular systolic function and promotes ventricular reverse remodeling.Good coronary collaterals exert a beneficial effect on left ventricular functional recovery after CTO-PCI,especially for non-diabetic patients.