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Circulation:放疗增加癌症患者心脏手术死亡率

来源:丁香园 2013-04-14 17:04

2013年4月8日—据《美国心脏学会》(American Heart Association)杂志发表的一项研究显示,与未接受放疗的肿瘤患者相比,接受胸部放疗的患者,在接受心脏大型手术后数年内死亡率增加近两倍。胸部放疗能杀灭或缩小乳腺肿瘤、霍奇金淋巴瘤和其他肿瘤;肿瘤患者接受放疗后,在接受大型心脏手术后数年甚至几十年后的死亡率增加。

俄亥俄州的克利夫兰诊所医学副教授,研究创始人Milind Desai博士说道:早在20世纪60年代末、70年代和80年代,放射治疗在改善儿童和成年肿瘤患者生存方面发挥重要作用;但该疗法往往对心脏有负面影响。与未接受放疗的患者相比,放疗患者发展为进行性冠状动脉疾病、恶性心瓣膜病、心包疾病的风险更大;这些病变均能影响心脏周围结构,且往往需要大型心脏手术。

此项研究是评估前期放疗对大型心脏手术长期影响的最大规模试验。研究人员对需要心脏手术的173例放疗的肿瘤患者开展回顾性研究,这些患者放疗和心脏手术平均间隔时间为18年。研究人员对这些心脏手术患者平均随访7.6年,并与未接受放疗但接受类似心脏手术的305例患者进行对比。

Desai称:这些手术多为心内直视手术,包括瓣膜或旁路手术,其中大部分为多项同步手术;例如多瓣膜手术或瓣膜加旁路手术。约1/4患者需要重做手术,这将增加已接受初次手术患者的死亡风险。

放疗患者的术前评分与非放疗患者相似。通常情况下,术前评分有助于预测患者术后病情进展。无论患者术前是否接受放疗,患者在术后30天内的预后情况相似。但是,在随访的7.6年间,接受放疗的肿瘤患者死亡率高达55%,而未放疗患者死亡率仅为28%。

Desai表示:该结果证实,尽管术前风险评分较低,但放疗可增加大型心脏手术死亡率。医生需为有胸部放疗史的患者制定更适宜的治疗方案,以确定心脏手术对患者有益;某些患者可能更适宜经皮穿刺手术。(生物谷Bioon.com)

Long-Term Survival of Patients With Radiation Heart Disease Undergoing Cardiac Surgery

Willis Wu, MD; Ahmad Masri, MD; Zoran B. Popovic, MD, PhD; Nicholas G. Smedira, MD; Bruce W. Lytle, MD; Thomas H. Marwick, MD, PhD; Brian P. Griffin, MD; Milind Y. Desai, MD

Background—Thoracic radiation results in radiation-associated heart disease (RAHD), often requiring cardiothoracic surgery (CTS). We sought to measure long-term survival in RAHD patients undergoing CTS, to compare them with a matched control population undergoing similar surgical procedures, and to identify potential predictors of long-term survival.

Methods and Results—In this retrospective observational cohort study of patients undergoing CTS, matched on the basis of age, sex, and type/time of CTS, 173 RAHD patients (75% women; age, 63±14 years) and 305 comparison patients (74% women; age, 63±4 years) were included. The vast majority of RAHD patients had prior breast cancer (53%) and Hodgkin lymphoma (27%), and the mean time from radiation was 18±12 years. Clinical and surgical parameters were recorded. The preoperative EuroSCORE and all-cause mortality were recorded. The mean EuroSCOREs were similar in the RAHD and comparison groups (7.8±3 versus 7.4±3, respectively; P=0.1). Proximal coronary artery disease was higher in patients with RAHD versus the comparison patients (45% versus 38%; P=0.09), whereas redo CTS was lower in the RACD versus the comparison group (20% versus 29%; P=0.02). About two thirds of patients in either group had combination surgical procedures. During a mean follow-up of 7.6±3 years, a significantly higher proportion of patients died in the RAHD group than in the comparison group (55% versus 28%; P<0.001). On multivariable Cox proportional hazard analysis, RAHD (2.47; 95% confidence interval, 1.82–3.36), increasing EuroSCORE (1.22; 95% confidence interval, 1.16–1.29), and lack of β-blockers (0.66; 95% confidence interval, 0.47–0.93) were associated with increased mortality (all P<0.01).

Conclusions—In patients undergoing CTS, RAHD portends increased long-term mortality. Alternative treatment strategies may be required in RAHD to improve long-term survival.

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