Sol ventrikül destek cihazlı (SVDC) hastalarda gelişen spontan intraserebral hemorajilere nöroşirurjikal yaklaşım ve mortalite üzerine etkileri
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Dosyalar
Tarih
2020
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Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Günümüzde, beklenen yaşam süresini uzatacak ve yaşam kalitesini arttıracak medikal gelişmeler yoğun bir şekilde yaşanmaktadır. Organ nakli de bu gelişmeler içinde önemli bir yer tutmaktadır. Verici kadavra sayısının yetersizliği ciddi sıkıntılar doğurmaktadır. Son dönem kalp yetmezliği (SDKY) tanılı hastalara sol ventrikül destek cihazı (SVDC) implantasyonu umut vermiş; ancak implantasyon sonrası yaşanan komplikasyonlar bu hastalarda önemli bir mortalite ve morbidite sebebi olmuştur. Spontan intraserebral hemoraji (İSH) SVDC implante hastalarda mortalite ve morbiditenin en sık nedenidir. SVDC implante hastalarda gelişen İSH'lara yönelik önceki çalışmalar travma nedenli intrakranial hemorajileri de içermektedirler. Bu serilerde cerrahi uygulanan hasta sayıları oldukça azdır ve sonuçları da kötüdür. Çalışmamızın amaçlarından bir tanesi de, SVDC implante hastalarda gelişen spontan İSH'ların nöroşirurjikal yönetimi açısından bir öncül bir klavuz oluşturulmasıdır. Ocak 2010-Mart 2020 arasında Ege Üniversitesi Tıp Fakültesi Hastanesi Kalp Damar Cerrahisi Anabilim Dalı'nda 450 hastaya SVDC implantasyonu yapılmıştır. Bu hastalardan İSH geçirenler geriye dönük olarak incelenmiştir. On sekiz yaşından küçük olgular, travmatik İSH'lar, subdural-epidural kanama gibi intraserebral yerleşimli olmayan intrakranial hemorajiler, tedaviyi reddedenler (1 hasta) ve genel durum bozukluğu/beyin sapı refleksleri olmaması sebebiyle cerrahi girişim düşünülmeyen (3 hasta) olgular dışlandı. Çalışma kriterlerine uyan toplam 60 hastanın dosyaları retrospektif olarak incelendi. İSH tanısıyla opere edilen toplam hasta sayısı 26'dır. Post-op 6 hasta sağ kalmıştır. Otuz dört hasta konservatif takip edilmiştir. 11'i aynı yatışta, 9'u da taburcu edildikten sonra farklı nedenlerle kaybedilmiştir. Aynı yatışta gelişen mortalite, tüm hastalarda %51.7, opere olan hastalarda %76.9, konservatif izlenen hastalarda %32.4 olarak hesaplanmıştır. Postop sağkalan altı hastanın üçünde Modifiye Rankin Skoru(mRS) 0'dır. Bu olgulara daha sonra ortotopik kalp nakli yapılmıştır. Taburcu edildiklerinde iki hastanın mRS'u 1 ve bir hastanın da mRS'u 4 olarak değerlendirilmiştir. Sağkalımı en fazla etkileyen prediktör olarak kanama sonrası Glasgow Koma Skoru (GKS) bulunmuş olup; sağ kalan tüm hasta grubunda sağkalanlarda ortalama 14.31 (SS:1.22, p<0.001), opere olan hasta grubunda sağkalanlarda ortalama 12.67 (SS:1.75, p:0.002), konservatif izlenen hasta grubunda sağkalanlarda ortalama 14.74 (SS:0.54, p:0.001) olarak bulunmuştur. Tüm hastalarda mortalite ile anlamlı ilişkisi saptanan diğer değişkenler Bilgisayarlı Beyin Tomografisinde (BBT) orta hat kayması (ortalama: 2.9 mm, SS: 4.8 mm, p:0.035), hidrosefali varlığı (9 hasta, p:0.002), kanama sonrası yatışında kan kültüründe üreme saptanması (21/37 hasta, p:0.049) bulunmuştur. Opere olan hastalarda CRP yüksekliği kreatinin klirensi, hidrosefali varlığının mortaliteye anlamlı etkisi olduğu gösterilmiştir. İSH tanısıyla yatış yapılan ama konservatif izlenen grupta, kan kültüründe üreme olması (9/15 hasta, p:0.025), mortaliteye etki eden bir faktördür. Cinsiyet, INR değeri, INR normalizasyon süresi, ortalama arteriyel basınç (OAB), cihaz tipi, postop antikoagülan başlama zamanı gibi değişkenlerin mortaliteye anlamlı etkileri gösterilmemiştir. SVDC implante hastalarda gelişen spontan İSH'ın etyopatogenezi hakkında tartışmalar devam etmektedir. Bu hastalarda cerrahi mortalite ve morbidite yüksektir ancak GKS'u 10 ve üzerindeyse, kanamaya bağlı kitle etkisi mevcutsa operasyon şansı verilmeli ve önerilmelidir. Kanama sonrası yatışta kan kültüründe üreme, CRP ve kreatinin yüksekliği, BBT'de orta hat kayması ve hidrosefali varlığının kötü prognostik faktörler olduğu akılda tutulmalıdır.
Recently, medical developments which enhance life expectancy and quality are intensely proceeding. Transplantation is an important constituent of these developments. The deficiency of donor cadaver is an important problem in this issue. The implantation of left ventricle assist device (LVAD) gives hope for patients who have end-stage heart failure (ESHF), but LVAD related complications account for high morbidity and mortality. In patients with LVADs, spontaneous intracerebral hemorrhage (ICH) is the hardest complication which accounts for highest morbidity and mortality. Previous studies about surgery in patients with LVAD related intracranial hemorrhage, include both traumatic and spontaneous intracranial hemorrhages. Those studies have small numbers of operated patients and outcomes are worse. The aim of this study is to become a guide for the neurosurgical management of LVAD related ICH. We have retrospectively inspected patients that have been implanted LVAD and treated with LVAD related ICH at Ege University’s Medical Faculty, Cardiovascular Surgery Division, between January 2010 – March 2020. We excluded patients: younger than 18 years of age, with trauma originated intracranial hemorrhage like subdural/epidural hematoma, with treatment refusal (one patient), or who haven’t had any surgical intervention because ofthe lack of brainstem reflexes (three patients). Patient demografics, data related heart failure and ICH have been analyzed to determine the predictors of mortality in 60 patients that fit the inclusion criteria. Twenty-six patients have been operated and 6 of them survived. Three of the 6 survivors were discharged with modified Rankin Score (mRS) 0 and orthotopic heart transplantation was performed to them after the discharge. Two of the 6 survivors were discharged with mRS 1 and one of them was discharged with mRS 4. Thirty-four patients were treated conservatively and 11 of them died on the same admission. Nine of 34 patients who were treated conservatively died after the discharge because of miscellaneous causes. The same admission mortality rate was found 51.7% for all patients, 76.9% for operated patients and 32.4% for conservatively treated patients. The initial Glasgow Coma Score (GCS) was found to be the strongest predictor of overall survival. The mean of initial GCS was found 14.31 (SD: 1.22, p < 0.001) in all patients, 12.67 (SD = 1.75, p = 0.002) in survived patients who were operated, 14.74 (SD:0.54, p:0.001) in survived patients who were conservatively treated. Presence of midline shift on computerized tomography (CT) scan (mean: 2.9 mm, SD:4.8 mm, p: 0.035), hydrocephalus (9 patients, p: 0.002) and bloodstream infection (21 of 37 patients, p: 0.049) were found to predict mortality rate in all patients. High CRP level, high level of creatinine clearance and presence of hydrocephalus (9 patients, p:0.04) were found to predict the mortality rate in operated patients. Bloodstream infection (p:0.025) was found a predictor of mortality in conservatively treated patients. There was no statistically significant effect of gender, level of INR, time to INR reversal, type of LVAD, timing of anticoagulation postoperatively and mean arterial pressure found on mortality rate. The etiology of LVAD related ICH can still not be explained. Although mortality and morbidty rate of surgery is too high, patients with a GCS bigger than10 and having a mass effect of hematoma should be given the chance to be operated. Bloodstream infections, high level of CRP and creatinin clearance, presence of midline shift and hydrocephalus on CT are also predictors of mortality to be considered beside the initial GCS.
Recently, medical developments which enhance life expectancy and quality are intensely proceeding. Transplantation is an important constituent of these developments. The deficiency of donor cadaver is an important problem in this issue. The implantation of left ventricle assist device (LVAD) gives hope for patients who have end-stage heart failure (ESHF), but LVAD related complications account for high morbidity and mortality. In patients with LVADs, spontaneous intracerebral hemorrhage (ICH) is the hardest complication which accounts for highest morbidity and mortality. Previous studies about surgery in patients with LVAD related intracranial hemorrhage, include both traumatic and spontaneous intracranial hemorrhages. Those studies have small numbers of operated patients and outcomes are worse. The aim of this study is to become a guide for the neurosurgical management of LVAD related ICH. We have retrospectively inspected patients that have been implanted LVAD and treated with LVAD related ICH at Ege University’s Medical Faculty, Cardiovascular Surgery Division, between January 2010 – March 2020. We excluded patients: younger than 18 years of age, with trauma originated intracranial hemorrhage like subdural/epidural hematoma, with treatment refusal (one patient), or who haven’t had any surgical intervention because ofthe lack of brainstem reflexes (three patients). Patient demografics, data related heart failure and ICH have been analyzed to determine the predictors of mortality in 60 patients that fit the inclusion criteria. Twenty-six patients have been operated and 6 of them survived. Three of the 6 survivors were discharged with modified Rankin Score (mRS) 0 and orthotopic heart transplantation was performed to them after the discharge. Two of the 6 survivors were discharged with mRS 1 and one of them was discharged with mRS 4. Thirty-four patients were treated conservatively and 11 of them died on the same admission. Nine of 34 patients who were treated conservatively died after the discharge because of miscellaneous causes. The same admission mortality rate was found 51.7% for all patients, 76.9% for operated patients and 32.4% for conservatively treated patients. The initial Glasgow Coma Score (GCS) was found to be the strongest predictor of overall survival. The mean of initial GCS was found 14.31 (SD: 1.22, p < 0.001) in all patients, 12.67 (SD = 1.75, p = 0.002) in survived patients who were operated, 14.74 (SD:0.54, p:0.001) in survived patients who were conservatively treated. Presence of midline shift on computerized tomography (CT) scan (mean: 2.9 mm, SD:4.8 mm, p: 0.035), hydrocephalus (9 patients, p: 0.002) and bloodstream infection (21 of 37 patients, p: 0.049) were found to predict mortality rate in all patients. High CRP level, high level of creatinine clearance and presence of hydrocephalus (9 patients, p:0.04) were found to predict the mortality rate in operated patients. Bloodstream infection (p:0.025) was found a predictor of mortality in conservatively treated patients. There was no statistically significant effect of gender, level of INR, time to INR reversal, type of LVAD, timing of anticoagulation postoperatively and mean arterial pressure found on mortality rate. The etiology of LVAD related ICH can still not be explained. Although mortality and morbidty rate of surgery is too high, patients with a GCS bigger than10 and having a mass effect of hematoma should be given the chance to be operated. Bloodstream infections, high level of CRP and creatinin clearance, presence of midline shift and hydrocephalus on CT are also predictors of mortality to be considered beside the initial GCS.
Açıklama
Anahtar Kelimeler
Sol Ventrikül Destek Cihazı, Spontan İntraserebral Hemoraji, Cerrahi, Mortalite, Left Ventricle Assist Device, Spontaneous Intracerebral Hemorrhage, Surgery, Mortality
