Early outcomes of heart transplantation in critical patients: single center experience of Fuwai Hospital
-
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. -
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。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)。 -
[1] CRESPO-LEIRO MG, METRA M, LUND LH, et al. Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology[J]. Eur J Heart Fail, 2018, 20(11): 1505-1535. DOI: 10.1002/ejhf.1236. [2] 韩宗茂, 高洁, 高传玉, 等. 晚期心力衰竭的治疗现状及研究进展[J]. 中华实用诊断与治疗杂志, 2020, 34(12): 1290-1293. DOI: 10.13507/j.issn.1674-3474.2020.12.026.HAN ZM, GAO J, GAO CY, et al. Current status of treatment and research progress of advanced heart failure[J]. J Chin Pract Diagn Ther, 2020, 34(12): 1290-1293. DOI: 10.13507/j.issn.1674-3474.2020.12.026. [3] HOOSAIN J, HANKINS S. Time is a precious commodity: 2018 OPTN policy change and the potential to lower heart transplant waitlist time in the sickest patients[J]. Curr Cardiol Rep, 2019, 21(7): 67. DOI: 10.1007/s11886-019-1150-8. [4] STEVENSON LW. Crisis awaiting heart transplantation: sinking the lifeboat[J]. JAMA Intern Med, 2015, 175(8): 1406-1409. DOI: 10.1001/jamainternmed.2015.2203. [5] COWGER JA. Addressing the growing U.S. donor heart shortage: waiting for godot or a transplant?[J]. J Am Coll Cardiol, 2017, 69(13): 1715-1717. DOI: 10.1016/j.jacc.2017.02.010. [6] KHUSH KK, POTENA L, CHERIKH WS, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: 37th adult heart transplantation report-2020; focus on deceased donor characteristics[J]. J Heart LungTransplant, 2020, 39(10): 1003-1015. DOI: 10.1016/j.healun.2020.07.010. [7] KHUSH KK, CHERIKH WS, CHAMBERS DC, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: thirty-sixth adult heart transplantation report - 2019; focus theme: donor and recipient size match[J]. J Heart Lung Transplant, 2019, 38(10): 1056-1066. DOI: 10.1016/j.healun.2019.08.004. [8] REICH H, RAMZY D, MORIGUCHI J, et al. Acceptable post-heart transplant outcomes support temporary MCS prioritization in the new OPTN|UNOS heart allocation policy[J]. Transplant Proc, 2021, 53(1): 353-357. DOI: 10.1016/j.transproceed.2020.04.1819. [9] RUSHTON S, PARAMESHWAR J, LIM S, et al. The introduction of a super-urgent heart allocation scheme in the UK: a 2-year review[J]. J Heart Lung Transplant, 2020, 39(10): 1109-1117. DOI: 10.1016/j.healun.2020.06.013. [10] VIEIRA JL, VENTURA HO, MEHRA MR. Mechanical circulatory support devices in advanced heart failure: 2020 and beyond[J]. Prog Cardiovasc Dis, 2020, 63(5): 630-639. DOI: 10.1016/j.pcad.2020.09.003. [11] SÁNCHEZ-ENRIQUE C, JORDE UP, GONZÁLEZ-COSTELLO J. Heart transplant and mechanical circulatory support in patients with advanced heart failure[J]. Rev Esp Cardiol (Engl Ed), 2017, 70(5): 371-381. DOI: 10.1016/j.rec.2016.12.036. [12] GAMBINO A. Challenges in heart transplantation: now and the future[J]. Transplant Proc, 2003, 35(8): 3069-3071. DOI: 10.1016/j.transproceed.2003.10.041. [13] PRIETO D, CORREIA P, ANTUNES P, et al. Results of heart transplantation in the urgent recipient-who should be transplanted?[J] Rev Bras Cir Cardiovasc, 2014, 29(3): 379-387. DOI: 10.5935/1678-9741.20140072. [14] 国家卫生健康委员会. 关于印发中国人体器官分配与共享基本原则和核心政策的通知[EB/OL]. [2021-03-31]. http://www.nhc.gov.cn/yzygj/s3586/201808/d35d96f2db82403ebe2ba41f2c583896.shtml. [15] GOFF RR, UCCELLINI K, LINDBLAD K, et al. A change of heart: preliminary results of the US 2018 adult heart allocation revision[J]. Am J Transplant, 2020, 20(10): 2781-2790. DOI: 10.1111/ajt.16010. [16] TRIVEDI JR, CHENG A, ISING M, et al. Heart transplant survival based on recipient and donor risk scoring: a UNOS database analysis[J]. ASAIO J, 2016, 62(3): 297-301. DOI: 10.1097/MAT.0000000000000337. [17] JOYCE DL, LI Z, EDWARDS LB, et al. Predicting 1-year cardiac transplantation survival using a donor-recipient risk-assessment tool[J]. J Thorac Cardiovasc Surg, 2018, 155(4): 1580-1590. DOI: 10.1016/j.jtcvs.2017.10.079. [18] OUYANG D, GULATI G, HA R, et al. Incidence of temporary mechanical circulatory support before heart transplantation and impact on post-transplant outcomes[J]. J Heart Lung Transplant, 2018, 37(9): 1060-1066. DOI: 10.1016/j.healun.2018.04.008. [19] YIN MY, WEVER-PINZON O, MEHRA MR, et al. Post-transplant outcome in patients bridged to transplant with temporary mechanical circulatory support devices[J]. J Heart Lung Transplant, 2019, 38(8): 858-869. DOI: 10.1016/j.healun.2019.04.003. [20] STERN LK, VELLECA A, NISHIHARA K, et al. Impact of the United Network for organ sharing 2018 donor heart allocation system on transplant morbidity and mortality[J]. Clin Transplant, 2021, 35(2): e14181. DOI: 10.1111/ctr.14181. [21] JASSERON C, LEGEAI C, JACQUELINET C, et al. Optimization of heart allocation: the transplant risk score[J]. Am J Transplant, 2019, 19(5): 1507-1517. DOI: 10.1111/ajt.15201. [22] HASANKHANI F, KHADEMI A. Efficient and fair heart allocation policies for transplantation[J]. MDM Policy Pract, 2017, 2(1): 1-12. DOI: 10.1177/2381468317709475. [23] SHAH KS, KITTLESON MM, KOBASHIGAWA JA. Updates on heart transplantation[J]. Curr Heart Fail Rep, 2019, 16(5): 150-156. DOI: 10.1007/s11897-019-00432-3. [24] MERLO A, BHATIA M. Pro: the new heart allocation system is a positive change in the listing of patients awaiting transplant[J]. J Cardiothorac Vasc Anesth, 2020, 34(7): 1962-1967. DOI: 10.1053/j.jvca.2020.02.042. [25] JIMENEZ J, BENNETT EDWARDS L, HIGGINS R, et al. Should stable UNOS status 2 patients be transplanted?[J]. J Heart Lung Transplant, 2005, 24(2): 178-183. DOI: 10.1016/j.healun.2003.10.019. [26] MOKADAM NA, EWALD GA, DAMIANO RJ JR, et al. Deterioration and mortality among patients with United Network for Organ Sharing status 2 heart disease: caution must be exercised in diverting organs[J]. J Thorac Cardiovasc Surg, 2006, 131(4): 925-926. DOI: 10.1016/j.jtcvs.2005.08.022. [27] LIETZ K, MILLER LW. Improved survival of patients with end-stage heart failure listed for heart transplantation: analysis of organ procurement and transplantation network/U.S. United Network of Organ Sharing data, 1990 to 2005[J]. J Am Coll Cardiol, 2007, 50(13): 1282-1290. DOI: 10.1016/j.jacc.2007.04.099. [28] TAYLOR LJ, FIEDLER AG. Balancing supply and demand: review of the 2018 donor heart allocation policy[J]. J Card Surg, 2020, 35(7): 1583-1588. DOI: 10.1111/jocs.14609. [29] CAI AW, ISLAM S, HANKINS SR, et al. Mechanical circulatory support in the treatment of advanced heart failure[J]. Am J Transplant, 2017, 17(12): 3020-3032. DOI: 10.1111/ajt.14403. [30] LOFORTE A, GLIOZZI G, MARIANI C, et al. Ventricular assist devices implantation: surgical assessment and technical strategies[J]. Cardiovasc Diagn Ther, 2021, 11(1): 277-291. DOI: 10.21037/cdt-20-325. [31] SPILIOPOULOS S, KOERFER R, TENDERICH G. Early outcomes with marginal donor hearts compared with left ventricular assist device support in patients with advanced heart failure: could the cardiac allocation score be the solution to the dilemma of therapy selection?[J] Ann Thorac Surg, 2016, 101(4): 1630. DOI: 10.1016/j.athoracsur.2015.08.082. [32] 吕鹏飞, 刘盛. 连续血流左心室辅助装置的发展现状[J]. 临床和实验医学杂志, 2019, 18(8): 894-897. DOI: 10.3969/j.issn.1671-4695.2019.08.033.LYU PF, LIU S. Development status of continuous blood flow left ventricular assist device[J]. J Clin Exp Med, 2019, 18(8): 894-897. DOI: 10.3969/j.issn.1671-4695.2019.08.033.