Effect of preoperative pulmonary artery pressure on perioperative prognosis of recipients with end-stage heart failure undergoing heart transplantation
-
摘要:
目的 探讨终末期心力衰竭受者术前肺动脉压对心脏移植围手术期预后的影响。 方法 回顾性分析行心脏移植手术的105例受者临床资料,以肺动脉平均压(mPAP)作为诊断标准,确定mPAP预测心脏移植预后的最佳临界值,根据临界值将受者分为低mPAP组(66例)和高mPAP组(39例)。比较低mPAP组和高mPAP组受者的术中指标(体外循环时间、主动脉阻断时间、辅助循环时间、供心冷缺血时间)和术后指标[主动脉内球囊反搏(IABP)支持率、IABP辅助时间、体外膜肺氧合(ECMO)支持率、ECMO辅助时间、机械通气时间、重症监护室(ICU)入住时间、三尖瓣中重度反流率、围手术期病死率],比较两组受者的预后情况。 结果 mPAP预测心脏移植预后的最佳临界值为30.5 mmHg。高mPAP组受者的ECMO支持率和围手术期病死率均高于低mPAP组(均为P < 0.05); 两组受者的体外循环时间、主动脉阻断时间、辅助循环时间、供心冷缺血时间、IABP支持率、IABP辅助时间、ECMO辅助时间、机械通气时间、ICU入住时间、三尖瓣中重度反流率差异均无统计学意义(均为P > 0.05)。高mPAP组和低mPAP组受者的术后1、2、3、4年的生存率间差异均无统计学意义(均为P > 0.05)。 结论 终末期心力衰竭患者术前肺动脉压力与心脏移植围手术期预后密切相关,mPAP=30.5 mmHg是预测心脏移植受者围手术期预后的最佳临界值,高mPAP组受者围手术期ECMO支持率高,围手术期病死率高,但并未对术后中、远期预后产生影响。 Abstract:Objective To evaluate the effect of preoperative pulmonary artery pressure on perioperative prognosis of the recipients with end-stage heart failure undergoing heart transplantation. Methods Clinical data of 105 recipients receiving heart transplantation were retrospectively analyzed. The mean pulmonary artery pressure (mPAP) was used as the diagnostic criterion. The optimal cut-off value of mPAP for predicting perioperative prognosis of heart transplant recipients was determined. According to the optimal cut-off value of mPAP, all recipients were divided into the low mPAP group (n=66) and high mPAP group (n=39). Intraoperative indexes (cardiopulmonary bypass time, aortic occlusion time, assisted circulation time and cold ischemia time of donor heart) and postoperative indexes [intra-aortic balloon pump (IABP) support rate, IABP support time, extracorporeal membrane oxygenation (ECMO) support rate, ECMO support time, mechanical ventilation time, length of ICU stay, incidence of moderate and severe tricuspid regurgitation and perioperative mortality rate] were compared between the low and high mPAP groups. The prognosis of the two groups was compared. Results The optimal cut-off value of mPAP in predicting clinical prognosis of heart transplant recipients was 30.5 mmHg. In the high mPAP group, the ECMO support rate and perioperative mortality rate were higher than those in the low mPAP group (both P < 0.05). No significant differences were observed in the cardiopulmonary bypass time, aortic occlusion time, assisted circulation time, cold ischemia time of donor heart, IABP support rate, IABP support time, ECMO support time, mechanical ventilation time, length of ICU stay and incidence of moderate and severe tricuspid regurgitation between two groups (all P > 0.05). No significant differences were noted in the 1-, 2-, 3- and 4- survival rates between two groups (all P > 0.05). Conclusions Preoperative mPAP in patients with end-stage heart failure is intimately correlated with perioperative prognosis of heart transplant recipients. The optimal cut-off value of mPAP in predicting perioperative prognosis of heart transplant recipients is 30.5 mmHg. In the high mPAP group, perioperative ECMO support rate and perioperative mortality rate are high, which do not affect the medium and long-term prognosis of the recipients undergoing heart transplantation. -
表 1 两组受者术中及术后指标的比较
Table 1. Comparison of intraoperative and postoperative parameters of recipients between the two groups
变量 低mPAP组(n=66) 高mPAP组(n=39) P值 体外循环时间(x±s,min) 139±42 150±38 0.127 主动脉阻断时间(x±s,min) 43±11 45±10 0.193 辅助循环时间(x±s,min) 89±43 96±41 0.321 供心冷缺血时间[M(P25,P75),min] 112(63,324) 132(72,326) 0.486 IABP支持率[n(%)] 10(15) 12(31) 0.057 IABP辅助时间[M(P25,P75),h] 156(100,227) 168(132,228) 0.772 ECMO支持率[n(%)] 7(11) 11(28) 0.021 ECMO辅助时间(x±s,h) 167±81 157±57 0.500 机械通气时间[M(P25,P75),h] 19(11,36) 24(12,51) 0.080 ICU入住时间(x±s,d) 13±6 13±6 0.981 三尖瓣中重度反流率[n(%)] 15(23) 10(26) 0.735 围手术期病死率[n(%)] 1(2) 6(15) 0.024 -
[1] 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. [2] 郑珊珊, 郑哲, 宋云虎, 等. 心脏移植术后移植物血管病: 阜外医院单中心长期随访结果总结[J]. 器官移植, 2022, 13(2): 206-212. DOI: 10.3969/j.issn.1674-7445.2022.02.008.ZHENG SS, ZHENG Z, SONG YH, et al. Cardiac allograft vasculopathy after heart transplantation: summary of a single-center long-term follow-up experience in Fuwai Hospital[J]. Organ Transplant, 2022, 13(2): 206-212. DOI: 10.3969/j.issn.1674-7445.2022.02.008. [3] POLASKA P, JERZAK-WODZYNSKA G, SMIGIELSKI W, et al. Long term outcome of heart failure patients disqualified from heart transplantation[J]. Acta Cardiol, 2021, 76(5): 525-533. DOI: 10.1080/00015385.2020.1852755. [4] ABU T, LEVI A, HASDAI D, et al. Preoperative evaluation of pulmonary hypertension in lung transplant candidates: echocardiography versus right heart catheterization[J]. BMC Cardiovasc Disord, 2022, 22(1): 53. DOI: 10.1186/s12872-022-02495-y. [5] SIMONNEAU G, MONTANI D, CELERMAJER DS, et al. Haemodynamic definitions and updated clinical classification of pulmonary hypertension[J]. Eur Respir J, 2019, 53(1): 1801913. DOI: 10.1183/13993003.01913-2018. [6] 王辉山. 终末期心力衰竭外科治疗新进展[J]. 创伤与急危重病医学, 2022, 10(3): 161-163. DOI: 10.16048/j.issn.2095-5561.2022.03.01.WANG HS. Recent advances in surgical treatment of end-stage heart failure[J]. Trauma Crit Care Med, 2022, 10(3): 161-163. DOI: 10.16048/j.issn.2095-5561.2022.03.01. [7] BOLLANO E, ANDERSSON B, HJALMARSSON C, et al. Early post-transplant elevated pulmonary artery pressure predicts adverse outcome in cardiac recipients[J]. Int J Cardiol Heart Vasc, 2019, 26: 100438. DOI: 10.1016/j.ijcha.2019.100438. [8] VACHIÉRY JL, TEDFORD RJ, ROSENKRANZ S, et al. Pulmonary hypertension due to left heart disease[J]. Eur Respir J, 2019, 53(1): 1801897. DOI: 10.1183/13993003.01897-2018. [9] AL-OMARY MS, SUGITO S, BOYLE AJ, et al. Pulmonary hypertension due to left heart disease: diagnosis, pathophysiology, and therapy[J]. Hypertension, 2020, 75(6): 1397-1408. DOI: 10.1161/HYPERTENSIONAHA.119.14330. [10] 郑珊珊, 刘盛. 终末期心力衰竭合并可逆性肺动脉高压患者心脏移植指征的探讨[J]. 器官移植, 2021, 12(2): 239-243. DOI: 10.3969/j.issn.1674-7445.2021.02.017.ZHENG SS, LIU S. Discussion on heart transplantation indications in patients with end-stage heart failure complicated with reversible pulmonary artery hypertension[J]. Organ Transplant, 2021, 12(2): 239-243. DOI: 10.3969/j.issn.1674-7445.2021.02.017. [11] CHAMBERS DC, PERCH M, ZUCKERMANN A, et al. The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: thirty-eighth adult lung transplantation report - 2021; focus on recipient characteristics[J]. J Heart Lung Transplant, 2021, 40(10): 1060-1072. DOI: 10.1016/j.healun.2021.07.021. [12] 中华医学会器官移植学分会. 中国心脏移植受者术前评估与准备技术规范(2019版)[J/CD]. 中华移植杂志(电子版), 2019, 13(1): 1-7. DOI: 10.3877/cma.j.issn.1674-3903.2019.01.001.Branch of Organ Transplantation of Chinese Medical Association. Technical specification for preoperative evaluation and preparation of heart transplant recipients in China (2019 edition)[J/CD]. Chin J Transplant (Electr Edit), 2019, 13(1): 1-7. DOI: 10.3877/cma.j.issn.1674-3903.2019.01.001. [13] 郑珊珊, 刘盛, 宋云虎, 等. 终末期心力衰竭合并肺动脉高压患者心脏移植的预后[J]. 中国循环杂志, 2022, 37(3): 226-233. DOI: 10.3969/j.issn.1000-3614.2022.03.004.ZHENG SS, LIU S, SONG YH, et al. Prognosis of end-stage heart failure patients with pulmonary hypertension post heart transplantation[J]. Chin Circ J, 2022, 37(3): 226-233. DOI: 10.3969/j.issn.1000-3614.2022.03.004. [14] CRAWFORD TC, LEARY PJ, FRASER CD 3RD, et al. Impact of the new pulmonary hypertension definition on heart transplant outcomes: expanding the hemodynamic risk profile[J]. Chest, 2020, 157(1): 151-161. DOI: 10.1016/j.chest.2019.07.028. [15] YAKUT K, VARAN B, ERDOĞAN İ, et al. Management of pediatric cardiac transplantation candidates with pulmonary hypertension and high pulmonary vascular resistance[J]. Turk J Pediatr, 2020, 62(3): 461-467. DOI: 10.24953/turkjped.2020.03.013. [16] GALIÈ N, HUMBERT M, VACHIERY JL, et al. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT)[J]. Eur Heart J, 2016, 37(1): 67-119. DOI: 10.1093/eurheartj/ehv317. [17] MATKOVIC M, MILICEVIC V, BILBIJA I, et al. Pulmonary artery hypertension as a risk factor for long-term survival after heart transplantation[J]. Heart Surg Forum, 2021, 24(3): E544-E549. DOI: 10.1532/hsf.3789. [18] BIEŁKA A, KALINOWSKI M, HAWRANEK M, et al. Mechanical circulatory support restores eligibility for heart transplant in patients with significant pulmonary hypertension[J]. Kardiol Pol, 2020, 78(10): 1008-1014. DOI: 10.33963/KP.15518. [19] MANDRAS SA, MEHTA HS, VAIDYA A. Pulmonary hypertension: a brief guide for clinicians[J]. Mayo Clin Proc, 2020, 95(9): 1978-1988. DOI: 10.1016/j.mayocp.2020.04.039. [20] HUSTON JH, BRITTAIN EL, ROBBINS IM. Pulmonary hypertension and right ventricular failure: lung transplant versus heart-lung transplant[J]. Cardiol Clin, 2020, 38(2): 269-281. DOI: 10.1016/j.ccl.2020.01.002. [21] COSTARD-JÄCKLE A, HILL I, SCHROEDER JS, et al. The influence of preoperative patient characteristics on early and late survival following cardiac transplantation[J]. Circulation, 1991, 84(5 Suppl): Ⅲ329-Ⅲ 337. [22] MOAYEDIFAR R, ZUCKERMANN A, ALIABADI-ZUCKERMANN A, et al. Long-term heart transplant outcomes after lowering fixed pulmonary hypertension using left ventricular assist devices[J]. Eur J Cardiothorac Surg, 2018, 54(6): 1116-1121. DOI: 10.1093/ejcts/ezy214. [23] AL-KINDI SG, FARHOUD M, ZACHARIAS M, et al. Left ventricular assist devices or inotropes for decreasing pulmonary vascular resistance in patients with pulmonary hypertension listed for heart transplantation[J]. J Card Fail, 2017, 23(3): 209-215. DOI: 10.1016/j.cardfail.2016.06.421. [24] 李雨琪, 贾明, 韩杰, 等. 心脏移植受者术后中远期疗效及死亡危险因素分析[J]. 中国医药, 2022, 17(1): 37-41. DOI: 10.3760/j.issn.1673-4777.2022.01.009.LI YQ, JIA M, HAN J, et al. Analysis of mid-to long-term efficacy and risk factors for death in patients after heart transplantation[J]. Chin Med, 2022, 17(1): 37-41. DOI: 10.3760/j.issn.1673-4777.2022.01.009. [25] 胡盛寿, 董念国, 魏翔, 等. 我国心脏移植现状分析——2013年中国心脏移植年度报告[J]. 中华器官移植杂志, 2014, 35(6): 324-328. DOI: 10.3760/cma.j.issn.0254-1785.2014.06.002.HU SS, DONG NG, WEI X, et al. Current situation of heart transplantation: Chinese heart transplant annual report 2013[J]. Chin J Organ Transplant, 2014, 35(6): 324-328. DOI: 10.3760/cma.j.issn.0254-1785.2014.06.002. [26] LUND LH, EDWARDS LB, KUCHERYAVAYA AY, et al. The registry of the international society for heart and lung transplantation: thirty-second official adult heart transplantation report--2015; focus theme: early graft failure[J]. J Heart Lung Transplant, 2015, 34(10): 1244-1254. DOI: 10.1016/j.healun.2015.08.003. [27] VAKIL K, DUVAL S, SHARMA A, et al. Impact of pre-transplant pulmonary hypertension on survival after heart transplantation: a UNOS registry analysis[J]. Int J Cardiol, 2014, 176(3): 595-599. DOI: 10.1016/j.ijcard.2014.08.072. [28] TAYLOR DO, EDWARDS LB, BOUCEK MM, et al. The Registry of the International Society for Heart and Lung Transplantation: twenty-first official adult heart transplant report--2004[J]. J Heart Lung Transplant, 2004, 23(7): 796-803. DOI: 10.1016/j.healun.2004.05.004. [29] BIRATI EY, RAME JE. Post-heart transplant complications[J]. Crit Care Clin, 2014, 30(3): 629-637. DOI: 10.1016/j.ccc.2014.03.005. [30] 黄洁. 阜外医院200例心脏移植病人中期生存率和影响因素与ISHLT结果对比分析研究[D]. 北京: 北京协和医学院(中国医学科学院), 2010.