Clinical application and perioperative echocardiographic evaluation of the magnetically levitated left ventricular assist device
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摘要: 目的 探讨超声心动图在磁悬浮左室辅助装置(LVAD)植入围术期评估中的临床应用价值。方法 回顾华中科技大学同济医学院附属协和医院接受磁悬浮LVAD植入手术的22例终末期心力衰竭患者的术前以及术后1个月的超声心动图检查参数，并对其进行评估与比较。术前超声心动图评估主要参数如下：左房内径、左室舒张期末期内径、右房横径、右室横径、肺动脉主干内径、右室面积变化率、三尖瓣环收缩期位移、三尖瓣环收缩期位移速度、左室射血分数、心输出量、主动脉瓣反流、二尖瓣反流、三尖瓣反流、下腔静脉内径, 肺动脉收缩压和心内分流情况。术后超声心动图监测指标增加了LVAD转速与流量、右心输出量、左室有无过度充盈或者过度抽吸、室间隔位置和主动脉瓣有无开放及反流变化。结果 22例患者均成功地进行了磁悬浮LVAD植入术，1例因多器官衰竭于术后14天死亡，21例患者术后恢复良好。与术前超声心动图参数比较，术后1个月患者的左房内径、左室舒张末期内径显著减小，肺动脉收缩压显著下降，心输出量显著提高(P < 0.05)，左室射血分数及右室收缩功能未见明显变化。术前4例患者合并主动脉瓣少量反流，复查时反流无明显变化，1例反流较重者直接进行主动脉瓣置换，此时所有患者主动脉瓣均开放。术前7例合并二尖瓣大量反流患者，LVAD植入同时行二尖瓣整形术，术后1个月7例患者反流量均减轻，其中4例为少至中量，3例为少量。术前4例合并三尖瓣大量反流患者，LVAD植入同时行三尖瓣整形术，术后1个月均未见明显反流。术后LVAD管道流速及流量运转正常，未出现左室过度充盈、过度抽吸现象以及不良事件。结论 磁悬浮LVAD可改善终末期心力衰竭患者左心重构，提高心功能。超声心动图可动态评估心脏大小、功能以及瓣膜功能，建立基线状态下的LVAD和自体心脏功能信息，在LVAD围术期评价中具有至关重要的临床价值。Abstract: Objective To investigate the clinical value of echocardiography in the implantation of magnetically levitated left ventricular assist device(LVAD).Methods Retrospectively analyze the clinical and echocardiographic data of 22 patients who implanted with the magnetically levitated LVAD at Union Hospital of Tongji Medical College of Huazhong University of Science and Technology, and compare the preoperative data with postoperative 1 month data. The preoperative echocardiographic parameters include: diameter of LA, RA, RV, PA and IVC, left ventricular end-diastolic diameter (LVIDd), RVFAC, TAPSE, s' of tricuspid ring TDI, LVEF, the cardiac output (CO), AR, MR, TR, the pulmonary artery systolic blood pressure (PASP), intracardiac shunt. Postoperative parameters added include: speed and output of LVAD, CO of RV, over filling or "sucking" of LV, position of IVS, opening and regurgitation change of AV..Results All 22 patients successfully underwent magnetically levitated LVAD implantation, in which 21 patients recovered well, 1 patient died of multi-organ failure in day-14 after surgery. Compared with the preoperative echocardiographic parameters, the left atrial diameter(LA) and left ventricular end-diastolic diameter(LVIDd) of patients at one month after surgery were significantly reduced, the pulmonary artery systolic blood pressure(PASP) was significantly reduced, the cardiac output(CO) was significantly improved(All P value were < 0.05), the left ventricular ejection fraction(LVEF) was slightly increased, and the right ventricular systolic function was not significantly changed. 4 patients with mild aortic regurgitation before surgery, which is still exist in 1 month. One patient with severe aortic regurgitation received replacement operation and all aortic valves open at follow up. There are 7 patients with severe mitral valve regurgitation before surgery. Thus, their LVAD implantation was accompanied by mitral valve plastic surgery, and the degree of regurgitation was reduced after surgery, in which 3 cases were mild and 4 cases were mild to moderate. LVAD implantation and tricuspid valve plastic surgery were conducted in 4 patients who were with severe tricuspid valve regurgitation preoperatively, and no significant regurgitation was detected in 1 month after surgery. After the operation, the flow rate of the LVAD was normal, and there was no left ventricular overfill, excessive suction and adverse events.Conclusion Magnetically levitated LVAD could improve left heart remodeling and enhance cardiac function in patients with end-stage heart failure. Echocardiography can evaluate the cardiac morphology and valve function dynamically, thus establish the basal information of LVAD and autologous heart, which is used to evaluate the efficacy of LVAD.
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Key words:
- left ventricular assist device /
- echocardiography
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表 1 两种LVAD特点比较
Table 1. Comparison of characteristics of two LVADs
项目 苏州同心
(CH-VAD)深圳核心医疗
(Corheart6)植入方式 心包腔 心包腔 轴承技术 磁悬浮 磁悬浮 泵体直径/mm 50 34 重量/g 180 90g 转速/(转/min) 2400~3000 2200~4300 最大流量/(L/min) 10 10 
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表 2 LVAD植入术患者的一般临床资料
Table 2. General data of patients with LVAD implantation
例(%), X±S 指标 数值(22例) 指标 数值(22例) 指标 数值(22例) LVAD类型/例(%) 收缩压/mmHg 110.6±29.9 手术持续时间/min 330.5±97.0 CH-VAD 8(36.4) 舒张压/mmHg 62.1±20.4ICU 时间/d 13±6 Corheart6 14(63.6) 心率/(次/min) 83.8±14.3 总住院时间/d 127±51 年龄/岁 50.1±15.0 NYHA心功能分级 术后并发症 男 18(81.2) Ⅳ级 10(45.5) 心包腔血栓 4(18.2) BMI/(kg/m2) 24.3±5.1 Ⅲ级 10(45.5) 多器官衰竭死亡 1(4.5) BSA/m2 1.82±0.36 Ⅱ级 2(9.0) 肺部感染 8(36.4) 原发病 同时进行的手术 扩张型心肌病 14(63.6) 三尖瓣整形术 4(26.7) 肥厚型心肌病 1(4.5) 二尖瓣整形术 7(46.7) 冠心病 6(27.4) 主动脉瓣置换术 1(6.6) 心瓣膜病 1(4.5) 左室血栓清除术 3(20.0)
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表 3 患者术前及术后随访生化指标
Table 3. Preoperative and postoperative follow-up biochemical indexes
X±S, M(P25, P75) 指标 术前 术后 P值 红细胞/(T/L) 3.6±1.2 3.1±0.7 0.238 血红蛋白/(g/L) 107.8±38.6 91.9±16.1 0.257 红细胞压积/% 32.7±11.3 28.0±5.2 0.274 血小板/% 186.3±45.1 162.9±92.6 0.480 尿素氮/(mmol/L) 10.0(7.3，15.9) 6.5(4.3，17.5) 0.208 肌酐/(μmol/L) 89.1(57.1，127.5) 66.2(54.9，95.7) 0.208 肾小球滤过率/(mL/min/1.73m2) 75.2±31.4 86.7±44.3 0.694 NT-proBNP/(pg/mL) 1 661.3(506.2，6 035.1) 563.7(217.2，919.1) 0.161 超敏肌钙蛋白/(ng/L) 659.5(50.5，2 439.1) 102.3(29.4，870.1) 0.499 C-反应蛋白/(mg/L) 25.3(3.1，70.9) 5.1(3.1，70.9) 0.866
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表 4 患者术前及术后随访超声指标
Table 4. Preoperative and postoperative follow-up ultrasound indexes
X±S 超声参数 术前 术后 P值 LA /mm 55.8±18.0 45.0±10.5 0.028 LVIDd/mm 78.9±15.5 65.0±12.2 0.015 RA/mm 42.2±9.7 36.6±4.7 0.065 RV/mm 37.4±10.1 35.2±4.6 0.672 PA/mm 30.6±10.4 28.0±5.1 0.339 RVFAC/% 34.8±9.7 35.5±5.3 0.807 TAPSE/mm 13.6±3.0 13.6±1.8 1.000 LVEF/% 26.2±4.2 31.7±7.6 0.090 PASP/mmHg 58.5±14.36 - - CO/(L/min) 4.9±1.6 6.8±2.1 0.001 LVAD转速/(转/min) - 2 752±210.37 - LVAD管道VTI /cm - 35.37±13.5 - LVAD管道流量/(L/min) - 5.07±1.57 - 注：VTI：速度时间积分。
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