LVAD后认知轨迹和终末期心力衰竭无改善的决定因素

摘要(中文译文)

认知功能障碍在终末期心力衰竭患者中较为常见，并可能对自我管理、治疗依从性以及左心室辅助装置（LVAD）植入后的临床结局产生不利影响。尽管LVAD支持可改善全身及脑灌注，但术后认知功能的变化轨迹仍存在异质性，且与认知功能未能改善相关的因素尚未明确，尤其是在亚洲人群中。本研究旨在描述LVAD植入后认知功能的变化特征，并识别认知功能未改善的临床、实验室、超声心动图及神经影像学决定因素。本单中心回顾性队列研究纳入56例接受LVAD植入的患者，患者于术前及术后约1年完成蒙特利尔认知评估（MoCA）。研究分析了人口学及临床特征、实验室参数（包括胆红素）、超声心动图指标（包括右心室面积变化分数[RV FAC]及瓣膜状态）以及头颅计算机断层扫描（CT）表现。采用配对t检验评估MoCA评分变化。采用单因素及多因素logistic回归分析识别与术后认知功能未改善相关的因素。LVAD植入前，56例患者中有39例（69.6%）MoCA评分<26，提示基线认知功能障碍患病率较高。认知功能障碍患者的饮酒史更为常见。植入后约1年，56例患者中有43例（76.8%）MoCA评分改善，总体MoCA评分较基线显著升高（P<0.05）。单因素分析中，缺血性心肌病、较低的RV FAC、较高的胆红素水平、头颅CT新发缺血性病灶及新发≥轻度主动脉瓣反流与认知功能未改善相关。多因素分析中，胆红素升高及新发≥轻度主动脉瓣反流仍与认知功能未改善独立相关。大多数终末期心力衰竭患者在LVAD植入后1年内出现显著的认知功能改善，而约四分之一的患者未出现改善。胆红素升高及新发≥轻度主动脉瓣反流可能有助于识别认知恢复受限风险较高的患者，并可能支持更密切的术后监测及更早的针对性干预。

Abstract

Cognitive impairment is common in patients with end-stage heart failure and may adversely affect self-management, treatment adherence, and clinical outcomes after left ventricular assist device (LVAD) implantation. Although LVAD support can improve systemic and cerebral perfusion, postoperative cognitive trajectories remain heterogeneous, and the factors associated with failure to improve are not well defined, particularly in Asian populations. This study aimed to characterize changes in cognitive function after LVAD implantation and to identify clinical, laboratory, echocardiographic, and neuroimaging determinants of cognitive non-improvement. This single-center retrospective cohort study included 56 patients who underwent LVAD implantation and completed the Montreal Cognitive Assessment (MoCA) before surgery and approximately 1 year after surgery. Demographic and clinical characteristics, laboratory parameters, including bilirubin, echocardiographic indices, including right ventricular fractional area change (RV FAC) and valvular status, and head computed tomography (CT) findings were analyzed. Changes in MoCA scores were assessed using a paired -test. Univariable and multivariable logistic regression analyses were performed to identify factors associated with postoperative cognitive non-improvement. Before LVAD implantation, 39 of 56 patients (69.6%) had a MoCA score <26, indicating a high prevalence of baseline cognitive impairment. Alcohol use was more frequent among patients with cognitive impairment. At approximately 1 year after implantation, 43 of 56 patients (76.8%) showed improved MoCA scores, and the overall MoCA score increased significantly from baseline (P<0.05). In univariable analysis, ischemic cardiomyopathy, lower RV FAC, higher bilirubin levels, incident ischemic lesions on head CT, and new-onset ≥mild aortic regurgitation were associated with cognitive non-improvement. In multivariable analysis, elevated bilirubin and new-onset ≥mild aortic regurgitation remained independently associated with cognitive non-improvement. Most patients with end-stage heart failure experienced significant cognitive improvement within 1 year after LVAD implantation, whereas approximately one quarter did not. Elevated bilirubin and new-onset ≥mild aortic regurgitation may help identify patients at increased risk of limited cognitive recovery and may support closer postoperative surveillance and earlier targeted intervention.

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