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危重状态病人心脏移植的早期结果:阜外医院单中心经验

郑珊珊 刘盛 唐汉韡 宋云虎 王巍 黄洁 廖中凯 郑哲

郑珊珊, 刘盛, 唐汉韡, 等. 危重状态病人心脏移植的早期结果:阜外医院单中心经验[J]. 器官移植, 2021, 12(4): 450-457. doi: 10.3969/j.issn.1674-7445.2021.04.012
引用本文: 郑珊珊, 刘盛, 唐汉韡, 等. 危重状态病人心脏移植的早期结果:阜外医院单中心经验[J]. 器官移植, 2021, 12(4): 450-457. doi: 10.3969/j.issn.1674-7445.2021.04.012
Zheng Shanshan, Liu Sheng, Tang Hanwei, et al. Early outcomes of heart transplantation in critical patients: single center experience of Fuwai Hospital[J]. ORGAN TRANSPLANTATION, 2021, 12(4): 450-457. doi: 10.3969/j.issn.1674-7445.2021.04.012
Citation: Zheng Shanshan, Liu Sheng, Tang Hanwei, et al. Early outcomes of heart transplantation in critical patients: single center experience of Fuwai Hospital[J]. ORGAN TRANSPLANTATION, 2021, 12(4): 450-457. doi: 10.3969/j.issn.1674-7445.2021.04.012

危重状态病人心脏移植的早期结果:阜外医院单中心经验

doi: 10.3969/j.issn.1674-7445.2021.04.012
基金项目: 

国家重点研发计划项目 2016YFC1300900

详细信息
    作者简介:

    郑珊珊,女,1995年生,博士研究生,研究方向为心脏移植、肺动脉高压、心脏瓣膜病等,Email:zhengshanshan1122@163.com

    通讯作者:

    郑哲,男,1971年生,博士,主任医师,研究方向为心脏移植、房颤的外科治疗、冠状动脉粥样硬化性心脏病的外科治疗、心脏瓣膜病等,Email:zhengzhe@fuwai.com

  • 中图分类号: R617, R541

Early outcomes of heart transplantation in critical patients: single center experience of Fuwai Hospital

More Information
  • 摘要:   目的  分析危重状态病人心脏移植的早期结果及其在供者分配决策中的意义。  方法  回顾性分析449例心脏移植受者的临床资料,根据术前状态分为危重状态组(64例)和一般状态组(385例)。总结危重状态的发生情况;比较两组受者的临床资料;分析两组受者术后生存情况及死亡原因;比较危重状态受者术前不同机械循环辅助桥接移植的围手术期结果。  结果  危重状态病人占总移植人数14.3%,近5年危重状态病人比例逐年增高。与一般状态组受者比较,危重状态组受者术前吸烟史比例较低,既往心脏手术史比例较高,血清肌酐水平较高,原发病为既往移植心脏衰竭比例较高;术后使用机械循环辅助比例较高,术后并发症发生率较高,重症监护室(ICU)入住时间较长,院内病死率较高(均为P≤0.01)。危重状态组受者术后1年生存率低于一般状态组受者(83%比95%,P < 0.01)。危重状态组受者因感染、多器官衰竭死亡的比例高于一般状态组受者。64例危重状态受者中,术前1例单独使用呼吸机,63例加用机械循环辅助桥接移植。其中49例(77%)单用主动脉内球囊反搏泵(IABP),8例(13%)联合应用体外膜肺氧合(ECMO)和IABP,4例(6%)单用ECMO,2例(3%)单用左心室辅助装置(LVAD)。术前应用ECMO、联合应用ECMO和IABP桥接移植的危重状态病人术后并发症发生的比例较高、ICU入住时间较长、机械通气时间较长,院内病死比例较高。  结论  危重状态病人心脏移植总体预后不佳,有效的术前管理可在一定程度逆转危重病人的高风险状态。供心分配应把有限的供心分配给最紧急且能从移植中受益最多的病人。

     

  • 图  1  2015年至2019年阜外医院心脏移植年病人量及危重状态病人所占比例

    Figure  1.  Number of heart transplant patients and proportionof critical patients in Fuwai Hospital from 2015 to 2019

    图  2  两组心脏移植受者术后生存曲线

    Figure  2.  Survival curves of heart transplant recipients after transplantation in two groups

    表  1  两组受者的临床资料比较

    Table  1.   Comparison of clinical data of recipients between two groups

    指标 危重状态组(n=64) 一般状态组(n=385) P
    术前资料
      受者年龄(x±s,岁) 44±13 46±15 0.31
      受者性别[n(%)] 0.61
        男 49(77) 283(74)
        女 15(23) 102(26)
      体质量指数(x±s,kg/m2 22±3 22±4 0.90
      吸烟史[n(%)] 7(11) 98(25) 0.01
      糖尿病病史[n(%)] 11(17) 69(18) 0.89
      高血压病史[n(%)] 3(5) 19(5) 0.93
      脑血管病史[n(%)] 0 15(4) 0.11
      既往心脏手术史[n(%)] 12(19) 32(8) 0.01
      术前植入ICD/CRT/CRTD[n(%)] 13(20) 89(23) 0.62
      血清肌酐(x±s,μmol/L) 115±48 96±32 < 0.01
      总胆红素(x±s,μmol/L) 25±12 24±10 0.46
      原发病
        原发性心肌病[n(%)] 45(70) 298(77) 0.19
        冠心病[n(%)] 8(12) 57(15) 0.63
        心脏瓣膜病[n(%)] 1(2) 14(4) 0.41
        先天性心脏病[n(%)] 1(2) 8(2) 0.79
        既往移植心脏衰竭[n(%)] 7(11) 4(1) < 0.01
        其他[n(%)] 2(3) 4(1) 0.20
      心脏循环指标
        需血管活性药物支持[n(%)] 57(89) 317(82) 0.18
        左心室射血分数(x±s,%) 26±8 30±12 0.39
        肺动脉高压[n(%)] 30(47) 162(42) 0.47
        平均肺动脉压(x±s,mmHg 25±12 24±10 0.46
        肺动脉收缩压(x±s,mmHg) 37±15 34±14 0.16
        肺动脉舒张压(x±s,mmHg) 19±9 17±8 0.06
      等待时间[MQ25, Q75),d] 13(7, 38) 18(6, 48) 0.33
      供者年龄(x±s,岁) 37±11 34±11 0.75
      供受者体质量不匹配[n(%)] 23(36) 140(36) 0.95
      供受者性别不匹配[n(%)] 16(25) 85(22) 0.60
    术中资料
      冷缺血时间[MQ25, Q75),min] 262(209, 375) 270(211, 360) 0.99
      体外循环时间[MQ25, Q75),min] 209(180, 255) 198(178, 236) 0.15
      主动脉阻断时间[MQ25, Q75),min] 73(58, 86) 69(60, 83) 0.67
      心脏功能低下[n(%)] 7(11) 39(10) 0.84
      三尖瓣返流[n(%)] 6(9) 35(9) 0.94
    术后资料
      使用机械循环辅助[n(%)] 37(58) 65(17) < 0.01
      并发症[n(%)] 18(28) 35(9) < 0.01
      机械通气时间[MQ25, Q75),h] 32(19, 65) 28(19, 42) 0.05
      ICU入住时间[MQ25, Q75),d] 6(4, 9) 4(3, 6) < 0.01
      住院时间[MQ25, Q75),d] 18(14, 22) 16(14, 22) 0.41
      出院时左心室射血分数(x±s,%) 64±6 63±7 0.60
      院内病死率[n(%)] 11(17) 15(4) < 0.01
      1年病死率[n(%)] 11(17) 18(5) < 0.01
    注:①ICD为植入式心律转复除颤器; CRT为心脏再同步治疗; CRTD为心脏再同步治疗除颤器。
    ②肺动脉高压指术前平均肺动脉压≥25 mmHg。
    ③10 mmHg=1.33 kPa。
    ④供受者体质量不匹配指供受者体质量之比 < 0.8或 > 1.2。
    下载: 导出CSV

    表  2  危重状态受者各类机械循环辅助桥接移植的围手术期情况

    Table  2.   Perioperative situation of critical recipients bridged transplantation with different mechanical circulation support devices

    类别 ECMO(n=4) IABP(n=49) LVAD(n=2) ECMO+IABP(n=8)
    术中术后使用机械循环辅助(n/N 2/4 27/49 0/2 8/8
    机械通气时间[MQ25, Q75),h] 258(108, 378) 25(19, 43) P1:14 214(59, 455)
    P2:19
    术后并发症(n/N 3/4 9/49 0/2 6/8
    ICU入住时间[MQ25, Q75),d] 12(5, 24) 5(4, 7) P1:6 11(7, 21)
    P2:7
    住院时间[MQ25, Q75),d] 18(6, 37) 18(14, 22) P1:16 16(8, 29)
    P2:20
    院内死亡(n/N 2/4 4/49 0/2 5/8
    术后1年内死亡(n/N 2/4 4/49 0/2 5/8
    注:①由于病例数较少,在定量资料中以每例实际值表示,P1指病例1(patient 1); P2指病例2(patient 2)。
    下载: 导出CSV
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  • 收稿日期:  2021-04-08
  • 网络出版日期:  2021-07-13
  • 刊出日期:  2021-07-15

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