Early outcomes of heart transplantation in critical patients: single center experience of Fuwai Hospital
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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。 -
关键词:
- 心脏移植 /
- 危重状态 /
- 一般状态 /
- 主动脉内球囊反搏泵（IABP） /
- 体外膜肺氧合（ECMO） /
- 左心室辅助装置（LVAD） /
- 供者分配 /
- 心力衰竭
Abstract:Objective To analyze the early outcomes of heart transplantation in critical patients and its significance in donor allocation decision. Methods Clinical data of 449 recipients undergoing heart transplantation were retrospectively analyzed. According to preoperative status, all patients were divided into the critical status group (n=64) and general status group (n=385). The incidence of critical status was summarized. Clinical data of recipients were statistically compared between two groups. Postoperative survival and causes of death in recipients between two groups were analyzed. Perioperative results of critical recipients undergoing different mechanical circulation support as a bridge to heart transplantation were compared. Results Critical patients accounted for 14.3% of the total number of transplant recipients. The proportion of critical patients gradually increased in recent 5 years. Compared with the general status group, the recipients in critical status group had a lower proportion of smoking history, a higher proportion of cardiac surgery history, a higher serum level of creatinine, and a higher proportion of primary diseases of heart failure before heart transplantation(all P≤0.01). The proportion of undergoing mechanical circulation support was higher, the incidence of complications was higher, the stay time in intensive care unit (ICU) was longer and the in-hospital fatality was higher after heart transplantation in the critical status group (all P≤0.01). The 1-year survival rate of recipients in critical status group was significantly lower than that in general status group (83% vs. 95%, P < 0.01). The fatality of recipients due to infection and multiple organ failure in critical status group was higher than that in general status group. Among 64 critical recipients, 1 recipient received ventilator alone, and 63 recipients underwent mechanical circulation support devices as a bridge to heart transplantation. Among them, intra-aortic balloon pump (IABP) alone was applied in 49 cases (77%), 8 cases (13%) of extracorporeal membrane oxygenation (ECMO) combined with IABP, 4 cases (6%) of ECMO alone, and 2 cases (3%) of left ventricular assist device (LVAD) alone. Critical patients who received preoperative ECMO and ECMO combined with IABP bridging to heart transplantation have a higher proportion of postoperative complications, a longer ICU stay time, a longer mechanical ventilation time, and a higher proportion of hospital deaths. Conclusions The overall prognosis of critical patients undergoing heart transplantation is relatively poor. Effective preoperative management may reverse the high-risk status of critical patients in a certain extent. The limited quantity of donor heart should be allocated to the most urgent patients who can obtain the greatest benefit from heart transplantation. -
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值 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/CRTD①[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②[n（%）] 30（47） 162（42） 0.47 平均肺动脉压（x±s，mmHg③） 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[M（Q25, 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④[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[M（Q25, Q75），min] 262（209, 375) 270（211, 360) 0.99 体外循环时间[M（Q25, Q75），min] 209（180, 255) 198（178, 236) 0.15 主动脉阻断时间[M（Q25, 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[M（Q25, Q75），h] 32（19, 65） 28（19, 42） 0.05 ICU入住时间[M（Q25, Q75），d] 6（4, 9） 4（3, 6） < 0.01 住院时间[M（Q25, 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。
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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）① 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[M（Q25, 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[M（Q25, Q75），d] 12（5, 24） 5（4, 7） P1：6 11（7, 21） P2：7 住院时间[M（Q25, 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）。
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