Uticaj slabosti desne srčane komore na klinički ishod implantacije uređaja za mehaničku cirkulatornu potporu leve srčane komore i postimplantaciono remodelovanje srca

Abstract

Slabost desne srčane komore (SDK) predstavlja najznačajniji kardiovaskularni patološki entitet sa dokazano negativnim uticajem na rezultate ugradnje uređaja za trajnu cirkulatornu potporu leve komore (LVAD). Cilj istraživanja je procena uticaja SDK na ishod implantacije LVAD uređaja uz indentifikovanje prediktivnih faktora za razvoj postimplantacione SDK. Obzirom da u kardiohirurškoj praksi dominira dilema vezana za odluku o ugradnji LVAD-a u grupi bolesnika sa preimplantacionom SDK dodatni fokus istraživanja bio je indentifikacija faktora koji doprinose oporavku funkcije desne komore i procesu reverznog remodelinga nakon ugradnje LVAD-a. Metod: Obavljena je retrospektivna kohortna studija u Univerzitetskom Kliničkom Centru Srbije. Analizirana je medicinska dokumentacija 92 bolesnika kojim je implantiran LVAD uređaj i koji su potom klinički praćeni u periodu od juna 2013. do marta 2021. godine. SDK je kategorisana prema prilagođenim kriterijumima Međunarodnog udruženja za transplantaciju srca i pluća. Klinički, ehokardiografski, laboratorijski, hemodimnamski parametri obezbeđivani su od strane istog multidisciplinarnog tima pre implantacije LVAD i nakon implantacije LVAD-a u vremenskim tačkama od 3, 6, 12 meseci i nakon svake naredne godine u toku redovnih ili vanrednih kontrola. Smrtni ishod i postimplantacione komplikacije unošeni su u bazu za period 30 dana od operacije, 3, 6, 12 meseci i svake naredne godine na redovnim ili vanrednim kontrolama. Statističkim analizama obezbeđeni su rezultati vezani za uticaj preimlantacione i postimplantacione SDK na ishod LVAD implantacije. Indentifikovani su prediktivni faktori za nastanak SDK, ustanovljena korelacija SDK sa drugim neželjenim događajima i obezbeđeni zaključci vezani za klinički proces potencijalnog oporavka desne komore nakon LVAD implantacije. Rezultati: U studiji je ukupno analizirano 92 pacijenta prosečne starosti 54,57 godina (standardna devijacija 12,16). Posmatrajući celu grupu jednomesečno preživljavanje je bilo 88,04%, šestomesečno 80,43%, jednogodišnje je bilo 70,65%, dok je dvogodišnje bilo 61,96%. Najznačajniji prediktori mortaliteta su bili niži INTERMACS profil, NYHA klasa IV i razvoj rane SDK (HR: 0,018, 11,100 i 10,681, respektivno).Kada se porede preživeli i preminuli bolesnici za period praćenja nakon LVAD implantacije, značajna razlika između ove dve analizirane grupe je nađena samo kod razvoja SDK u ranom obliku (p<0,001). Preoperativna SDK je bila prisutna kod 24 bolesnika, 12 kojih su preminuli i 12 koji su bili živi do preseka studije nakon LVAD implantacije. Najznačajniji prediktori razvoja postimplantacione SDK bili su povišen nivo BNP, povišen CVP/PCWP skor, SDK pre operacije, FAC < 20%, prethodna bubrežna insuficijencija i ukupno trajanje boravka na intenzivnoj intenzivnoj nezi (HR: 1,002, 0,901, 0,858, 23,554 i 1,005). Kod 4 bolesnika razvila se kasna forma SDK. Prikazana je jasna razlika u varijablama kod 24 pacijenta sa preoperativnom SDK u odnosu na razvoj postoperativne SDK nakon implantacije LVAD gde je među bolesnicima sa postoperativnim SDK, CVP/PCVP skor je pre implantacije bio značajno viši (p=0,023), a eGFR je bila značajno niža nego kod pacijenata kod kojih je SDK imala reverzibilni karakter nakon implantacije LVAD (p=0,049). Pored toga, pokazalo se da je dilatativna kardiomiopatija najčešći etiološki uzrok postoperativne SDK u ovoj izolovanoj grupi (p=0,050). Ispitivanjem povezanosti SDK pre i nakon implantacije LVAD-a sa neželjenim rekacijama prikazan je visok stepen korelacije sa renalnom insuficijencijom na dijalizi (r=0,210/0,281, p=0,037/0,007) i sa MOS (r=0,308/0,694, p=0,003/<0,001). Vezano za anatomske i fiziološke promene miokarda nakon LVAD implantacije nađena je statistički značajna diferencijacija u FAC DK koja je bila veća, u veličini DK u cm koja je bila manjih dimenzija i stepenu trikuspidalne regurgitacije preoperativno i nakon 3 meseca kako u grupi koja preoperativnobila bez SDK tako i u grupi koja je imala preoperativno SDK...

Right heart failure (RHF) is the most significant cardiovascular pathological entity with a proven negative impact on the results of implantation of a device for permanent circulatory support of the left ventricle (LVAD). The aim of the research is to evaluate the impact of RHF on the outcome of LVAD device implantation while identifying predictive factors for the development of post- implantation RHF. Considering that the dilemma related to the decision to implant LVAD in the group of patients with pre-implantation RHF dominates in cardiac surgery practice, an additional focus of the research was the identification of factors that contribute to the recovery of right ventricular function and the process of reverse remodeling after LVAD implantation. Method: A retrospective cohort study was performed at the University Clinical Center of Serbia. The medical records of 92 patients implanted with an LVAD device and then clinically monitored in the period from June 2013 to March 2021 were analyzed. RHF is categorized according to adapted criteria of the International Association for Heart and Lung Transplantation. Clinical, echocardiographic, laboratory, hemodynamic parameters were provided by the same multidisciplinary team before LVAD implantation and also after LVAD implantation at 3, 6, 12 months respectively and every subsequent year for regular or irregular follow-ups. Mortality and post-implantation complications were entered into the database at 30 days after the operation, at 3, 6, 12 months and every subsequent year during regular or irregular follow-ups. Statistical analyzes provided results related to the influence of pre- implantation and post-implantation RHF on the outcome of LVAD implantation. Predictive factors for the occurrence of RHF were identified, the correlation of RHF with other adverse events was established, and conclusions related to the clinical process of potential right ventricular recovery after LVAD implantation was provided. Results: A total of 92 patients with an average age of 54.57 years (standard deviation 12.16) were analyzed in this study. Observing the whole group, one-month survival was 88.04%, six-month survival was 80.43%, one-year survival was 70.65%, while two-year survival was 61.96%. The most significant predictors of mortality were a lower INTERMACS profile, NYHA class IV and the development of early RHF (HR: 0.018, 11.100 and 10.681, respectively). When comparing the survived and deceased patients for the follow-up period after LVAD implantation, the significant difference between the two analyzed groups was found only with early development of RHF (p<0.001). Pre-operative RHF was present in 24 patientsafter LVAD implantation, 12 of whom were deceased and 12 of whom were alive at the study cut-off. The most significant predictors of the development of post- implantation RHF were elevated BNP level, elevated CVP/PCWP score, RHF before surgery, FAC < 20%, previous renal insufficiency and total duration of ICU stay (HR: 1.002, 0.901, 0.858, 23.554 and 1.005). In 4 patients, the late form of RHF developed. A significant difference in variables was shown in 24 patients with preoperative RHF compared to the development of postoperative RHF after LVAD implantation, where among patients with postoperative RHF, CVP/PCVP score before implantation was significantly higher (p=0.023), and eGFR was significantly lower than in patients whose RHF had a reversible character after LVAD implantation (p=0.049). In addition, dilated cardiomyopathy was shown to be the most common etiological cause of postoperative RHF in this isolated group (p=0.050). Examining the association of RHF before and after LVAD implantation with adverse reactions showed a high degree of correlation with renal insufficiency on dialysis (r=0.210/0.281, p=0.037/0.007) and with MOF (r=0.308/0.694, p=0.003/ <0.001)...