CHICAGO (EGMN) –Early postoperative liver dysfunction is common following implantation of the Heartmate II left ventricular assist device, according to findings from a retrospective study.
In fact, 14 (25%) of 57 patients who had Heartmate II implantation as a bridge to transplant or as destination therapy between June 2005 and April 2008 developed early postoperative liver dysfunction (EPOLD). The condition was defined as a bilirubin level of 7 mg/dL or greater within 7 days of implantation, Dr. Elizabeth Ziemba reported in a poster at the annual meeting of the International Society for Heart and Lung Transplantation.
Survival, however, did not appear to be affected by the development of EPOLD.
Patients with elevated preoperative total bilirubin levels were at particular risk of developing EPOLD (odds ratio 7.046), suggesting that preexisting liver dysfunction is most likely an important risk factor for EPOLD.
Another factor associated with EPOLD was poor preoperative nutrition status as evidenced by low prealbumin levels (OR 0.856).
“If possible, nutritional status must be optimized before LVAD placement,” Dr. Ziemba wrote.
Although right heart failure is a known risk factor for liver dysfunction in LVAD patients, central venous pressure was not found to be a predictor of EPOLD, noted Dr. Ziemba of the surgery department at the University of Minnesota, Minneapolis.
All patients in the study were treated at the university and underwent standard heart failure therapy before implantation. Pump speed was set to provide adequate cardiac output while achieving optimal left ventricular decompression, and the pulsatility index was maintained at 3.5-5.0. The pump speed also was optimized both hemodynamically and echocardiographically before final hospital discharge, she noted.
Patients who developed EPOLD experienced a prolonged postoperative recovery of bilirubin levels. The levels increased in both groups postoperatively, and peaked on about day 3 at 9.78 mg/dL in the EPOLD patients and on day 1 at about 3.5 mg/dL in the non-EPOLD patients. Levels returned to near the baseline value of 1.5 mg/dL in 60 days in the EPOLD patients, compared with only 5 days in the non-EPOLD patients.
Despite the high prevalence of EPOLD in this study, the overall survival of patients with a Heartmate II LVAD at 6 months was excellent, at 82.5%. Survival in those without liver dysfunction was 84%, and survival in those with EPOLD was 79%, Dr. Ziemba reported.
Indeed, LVADs have “revolutionized the treatment options available for patients with end-stage heart failure,” she wrote.
She concluded, however, that the multifactorial effect of liver dysfunction on LVAD outcomes, including mortality, deserves further evaluation.
Dr. Ranjit John reported receiving research grant support from Thoratec, which developed the Heartmate II device. The other authors reported having no financial or other relevant conflicts.
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芝加哥(EGMN)——根据一项回顾性研究结果，植入Heartmate II型左心室辅助系统(LVAD)的患者在术后早期常会出现肝功能异常。
Elizabeth Ziemb博士在国际心肺移植协会年会上以壁报形式报告了其研究成果。她及其同事回顾分析了57名于2005年6月~2008年4月间作为心脏移植前过渡治疗或作为最终治疗而接受Heartmate II型LVAD植入手术的患者。结果显示，其中14名(25%)患者出现术后早期肝功能异常(EPOLD)，表现为植入术后7 天内胆红素水平达到或超过7 mg/dl。
然而，患者生存期似乎不受出现EPOLD的影响。
术前存在总胆红素水平升高的患者出现EPOLD的危险性更高(比值比为7.046)，提示术前存在肝功能异常很可能是EPOLD的一个重要危险因素。
另一个与EPOLD相关的危险因素是术前患者营养状况差，可表现为前白蛋白水平低(比值比为0.856)。
Ziemba博士写道：“如果可能，必须在LVAD植入前使患者营养状况处于最佳状态。”
Ziemba博士来自明尼阿波利斯市明尼苏达大学外科。她强调，虽然右心衰竭是LVAD植入患者出现肝功能异常的危险因素，但并未发现中心静脉压是EPOLD的一个预测因素。
该研究所涉及的所有患者均在明尼苏达大学接受治疗，并在移植术前接受标准的抗心衰治疗。所设定的泵速可提供充足的心脏输出血量，从而令左心室处于最佳减压状态，并使心搏指数保持在3.5~5.0。Ziemba博士强调，在最终出院前，患者的泵速经血流动力学和超声心动图检测都显示处于最佳状态。
出现EPOLD的患者术后胆红素水平恢复时间有所延长。胆红素水平在两组患者术后均升高，其峰值在EPOLD患者出现在术后第3天，达9.78 mg/dl；而在非EPOLD患者则出现在术后第1天，约为3.5 mg/dl。EPOLD患者恢复到基线水平1.5 mg/dl需60 天，而非EPOLD患者仅需5 天。
尽管在该研究中EPOLD的发病率较高，但患者植入Heartmate II型LVAD后6个月时的总生存率非常高，达82.5%。根据Ziemba博士的报告，没有肝功能异常的患者生存率达84%，而EPOLD患者也达到79%。
她认为，实际上，LVAD为“终末期心衰患者治疗方式的选择上带来了革命性的突破”。
她指出，虽然如此，但肝功能异常对LVAD疗效的多方面影响，包括对病死率的影响，仍值得进一步研究。
Ranjit John博士声称接受了Heartmate II型设备研制者Thoratec公司的研究资金支持。其他作者称没有经济或其他相关利害关系。
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