【罂粟摘要】术前中心静脉压预估与Fontan术后急性心功能衰竭的关系
术前中心静脉压预估与Fontan术后急性心功能衰竭的关系
贵州医科大学 高鸿教授课题组
翻译：曹莹 编辑：佟睿 审校：曹莹
Fontan术后急性心功能衰竭是全腔静脉肺动脉连接术（Total Cavopulmonary Connection，TCPC）后的一系列并发症，其特征为高中心静脉压、低心排以及对药物治疗反应不佳。本研究旨在利用常规术前评估可获取的数据来预估TCPC术后患者的中心静脉压（Central Venous Pressure，CVP），以期探讨术前数据评估和术后CVP之间的关系，以及是否和Fontan术后急性心功能衰竭相关。
本项回顾性研究纳入了131例行TCPC的患者。术前通过心脏MRI成像估计患者CVP，全身麻醉下行TCPC时测量术中的CVP，而术后从电子病历中收集入住ICU 24小时内的CVP。Fontan术后急性心功能衰竭定义为患者死亡、心脏移植、TCPC拆除或术后30天内管道开窗技术。
行TCPC的患者术后入ICU 24小时内的CVP与预估CVP显著相关（r =0.26, P=0.03），尤其是未行管道开窗的患者（r =0.45, P=0.01）。TCPC术中CVP与Fontan术后急性心功能衰竭显著相关（OR：1.1，95% CI：1.01-1.21，p=0.03）。CVP 33mmHg可作为阈值，TCPC术中CVP等于或高于 33mmHg对于识别Fontan术后急性心功能衰竭具有极高的特异性（90%）和敏感性（58%）（ROC曲线下面积=0.73；OR：12.4，95% CI：2.5-62.3，p=0.002）。上述相关性在单上腔静脉患者中相关性更强。
计算TCPC CVP方法的图解说明。该方法试图估计在TCPC完成后，如果全身血流都指向肺动脉，则CVP的变化。A，在BCPC期，测量SVC流量和CVPSVC，计算忽略远端心房压力的PVR估计数。B，使用PVR和假定的TCPC流量乘积计算CVPTCPC估计数:主动脉血流或SVC þ IVC血流。通过这种方式，BCPC CVP与TCPC循环中的预期流量成比例。BCPC，双向腔肺连接;SVC，上腔静脉;PVR:肺血管阻力;WU:Wood单元;CVP:中心静脉压;TCPC，全腔肺连接。
综合术前压力和血流动力学数据预估TCPC患者CVP是一项较简易的指标。TCPC患者预测较高的CVP可增加Fontan术后急性心功能衰竭风险，与TCPC术后直接测量的CVP相关。对于Fontan术后急性心功能衰竭风险的识别有助于指导风险缓解策略。
Michael A. Quail, MRCPH, PhD,a Ignatius Chan, BSc, et al. A preoperative estimate of central venous pressure is associated with early Fontan failure. [J]J Thorac Cardiovasc Surg 2020; XX:1-9)
A preoperative estimate of central venous pressure is associated with early Fontan failure
Abstract
Objective: Early Fontan failure is a serious complication after total cavopulmonary connection, characterized by high central venous pressure, low cardiac output, and resistance to medical therapy. This study aimed to estimate postoperative central venous pressure in patients with total cavopulmonary connection using data routinely collected during preoperative assessment. We sought to determine if this metric correlated with measured postoperative central venous pressure and if it was associated with early Fontan failure.
Methods: In this retrospective study, central venous pressure in total cavopulmonary connection was estimated in 131 patients undergoing pre–total cavopulmonary connection assessment by cardiac magnetic resonance imaging and central venous pressure measurement under general anesthesia. Postoperative central venous pressure during the fifirst 24 hours in the intensive care unit was collected from electronic patient records in a subset of patients. Early Fontan failure was defifined as death, transplantation, total cavopulmonary connection takedown, or emergency fenestration within the fifirst 30 days.
Results: Estimated central venous pressure in total cavopulmonary connection correlated signifificantly with central venous pressure during the fifirst 24 hours in the intensive care unit (r = 0.26, P = .03), particularly in patients without a fenestration (r = 0.45, P = .01). Central venous pressure in total cavopulmonary connection was signifificantly associated with early Fontan failure (odds ratio, 1.1; 95% confifidence interval, 1.01-1.21; P = .03). A threshold of central venous pressure in total cavopulmonary connection 33 mm Hg or greater was found to have the highest specifificity (90%) and sensitivity (58%) for identifying early Fontan failure (area under receiver operating curve = 0.73; odds ratio, 12.4; 95% confifidence interval, 2.5-62.3; P= .002). This association was stronger in patients with single superior vena cava.
Conclusions: Estimated central venous pressure in total cavopulmonary connection is an easily calculated metric combining preoperative pressure and flflow data. Higher central venous pressure in total cavopulmonary connection is associated with an increased risk of early Fontan failure and is correlated with directly measured post–total cavopulmonary connection pressure. Identifification of patients at risk of early Fontan failure has the potential to guide riskmitigation strategies.