J Thorac Cardiovasc Surg：左心室辅助装置 VS常规手术

　　严重的缺血性心肌病（左心室射血分数<25％）和重度缺血性二尖瓣关闭不全的患者单纯药物治疗预后较差。常规意义上，作为目标治疗的左心室辅助装置通常用于常规手术风险太高的患者。近期，发表于The Journal of Thoracic and Cardiovascular Surgery上一篇文章的评估了对于这类患者传统的手术和这个疗法的效益。

　　该研究纳入了接受常规手术或接受作为目标治疗的左心室辅助装置的严重的缺血性心肌病（左心室射血分数<25％）和重度二尖瓣关闭不全的患者。

　　该研究常规手术于1993至2009年进行，并从2007年至2011年开始使用左心室辅助装置。他们比较了这些患者的终末器官功能和生存的患者的特征。研究共纳入88例患者，其中55例患者行常规手术（63％），33例（37％）接受左心室辅助装置。

　　研究结果发现，在接受左心室辅助装置的患者中肾功能衰竭，正性肌力药物依赖，主动脉内球囊支持的比例增加。接受传统手术的患者需要更长的通气支持，接受左心室辅助装置的患者因出血需要更多的手术。两组30天死亡率相似，在常规手术组为7％，在左心室辅助装置组为3％，P=0.65，1年死亡率分别为22％对15％，P=0.58）。接收左心室辅助装置的患者在1年时间中生存的趋势倾向于改善（94％对71％，P =0.171）。

　　研究结果提示：常规手术后手术死亡率和早期生存率是可以接受的。对于不能手术的患者，左心室辅助装置可以提供类似的结果。

Management of severe ischemic cardiomyopathy: Left ventricular assist device as destination therapy versus conventional bypass and mitral valve surgery
Objectives
Patients with severe ischemic cardiomyopathy (left ventricular ejection fraction <25%) and severe ischemic mitral regurgitation have a poor survival with medical therapy alone. Left ventricular assist device as destination therapy is reserved for patients who are too high risk for conventional surgery. We evaluated our outcomes with conventional surgery within this population and the comparative effectiveness of these 2 therapies.
Methods
We identified patients who underwent conventional surgery or left ventricular assist device as destination therapy for severe ischemic cardiomyopathy (left ventricular ejection fraction <25%) and severe mitral regurgitation. The era for conventional surgery spanned from 1993 to 2009 and from 2007 to 2011 for left ventricular assist device as destination therapy. We compared baseline patient characteristics and outcomes in terms of end-organ function and survival.
Results
A total of 88 patients were identified; 55 patients underwent conventional surgery (63%), and 33 patients (37%) received a left ventricular assist device as destination therapy. Patients who received left ventricular assist device as destination therapy had the increased prevalence of renal failure, inotrope dependency, and intra-aortic balloon support. Patients undergoing conventional surgery required longer ventilatory support, and patients receiving a left ventricular assist device required more reoperation for bleeding. Mortality rates were similar between the 2 groups at 30 days (7% in the conventional surgery group vs 3% in the left ventricular assist device as destination therapy group, P = .65) and at 1 year (22% in the conventional surgery group vs 15% in the left ventricular assist device as destination therapy group, P = .58). There was a trend toward improved survival in patients receiving a left ventricular assist device compared with the propensity-matched groups at 1 year (94% vs 71%, P = .171).
Conclusions
The operative mortality and early survival after conventional surgery seem to be acceptable. For inoperable or prohibitive-risk patients, left ventricular assist device as destination therapy can be offered with similar outcomes.