目的:缺血性心肌病患者手术心室重建(SVR)的作用存在争议。观察性系列试验和同位素心力衰竭的外科治疗(STICH)试验报告了矛盾的结果。SVR高度依赖于操作者的经验。这项研究的目的是使用单个患者数据比较大量SVR机构和STICH试验之间SVR的长期结果。
方法:通过逆概率治疗加权Cox回归将在圣多纳托医院(米兰)接受SVR的患者与在STICH(治疗原则)中接受SVR的患者进行比较。主要结果是全因死亡率。
结果:SanDonato队列包括725名患者,而STICH队列包括501。与STICH-SVR队列相比,圣多纳托患者年龄较大(66.0,四分位数较低,上四分位数[Q1,Q3:58.0,72.0]vs61.9[Q1,Q3:55.1,68.8],P<.001)和基线时左心室收缩末期容积指数较低(LVESVI:77.0[Q1,Q3:59.0,97.0]vs80.8[Q1,Q3:58.5,106.8],P=.02)。倾向得分加权产生了2个相似的队列。在4年的随访中,与STICH-SVR队列相比,SanDonato队列的死亡率显着降低(调整后的风险比,0.71;95%置信区间,0.53-0.95;P=.001)。术后LVESVI增高与死亡率独立相关(风险比,1.02;95%置信区间,1.01-1.03)。在随访4至6个月时,SanDonato队列中LVESVI的平均降低为39.6%,STICH-SVR队列中的10.7%(P<.001)。
结论:在高容量SVR机构接受SVR的梗死后左心室重塑患者的长期结果优于STICH试验中报告的结果。这表明可能需要对SVR假设进行新的试验。
OBJECTIVE: The role of surgical ventricular reconstruction (SVR) in patients with ischemic cardiomyopathy is controversial. Observational series and the Surgical Treatment of IsChemic Heart failure (STICH)
trial reported contradictory results. SVR is highly dependent on operator experience. The aim of this
study is to compare the long-term results of SVR between a high-volume SVR institution and the STICH
trial using individual patient data.
METHODS: Patients undergoing SVR at San Donato Hospital (Milan) were compared with patients undergoing SVR in STICH (as-treated principle) by inverse probability treatment-weighted Cox regression. The primary outcome was all-cause mortality.
RESULTS: The San Donato cohort included 725 patients, whereas the STICH cohort included 501. Compared with the STICH-SVR cohort, San Donato patients were older (66.0, lower quartile, upper quartile [Q1, Q3: 58.0, 72.0] vs 61.9 [Q1, Q3: 55.1, 68.8], P < .001) and with lower left ventricular end-systolic volume index at baseline (LVESVI: 77.0 [Q1, Q3: 59.0, 97.0] vs 80.8 [Q1, Q3: 58.5, 106.8], P = .02). Propensity score weighting yielded 2 similar cohorts. At 4-year follow-up, mortality was significantly lower in the San Donato cohort compared with the STICH-SVR cohort (adjusted hazard ratio, 0.71; 95% confidence interval, 0.53-0.95; P = .001). Greater postoperative LVESVI was independently associated with mortality (hazard ratio, 1.02; 95% confidence interval, 1.01-1.03). At 4 to 6 months of follow-up, the mean reduction of LVESVI in the San Donato cohort was 39.6%, versus 10.7% in the STICH-SVR cohort (P < .001).
CONCLUSIONS: Patients with postinfarction LV remodeling undergoing SVR at a high-volume SVR institution had better long-term results than those reported in the STICH
trial, suggesting that a new
trial testing the SVR hypothesis may be warranted.