回顾性分析单中心7例心脏移植术后死亡的受者资料，探讨心脏移植术后死亡危险因素。

2015年5月1日至2019年5月1日武汉大学人民医院心血管外科共实施74例原位心脏移植，术式均采用双腔静脉法。截至2020年4月，中位随访时间724 d，65例受者存活，9例死亡。排除2例非医疗原因死亡病例，将受者分为存活组(65例)和死亡组(7例)。收集两组受者术前、术中和围手术期指标以及对应供者情况。对符合正态分布的连续变量采用t检验比较，非正态分布的连续变量采用Kruskal-Wallis检验。计数资料采用Fisher确切概率法比较。采用Kaplan-Meier法绘制生存曲线。采用Cox比例风险模型分析心脏移植术后死亡危险因素。

7例死亡受者中，4例受者住院期间因移植心脏衰竭、排斥反应、呼吸衰竭及其他脏器功能衰竭死亡，其中1例为心肺联合移植受者；3例受者随访期间死亡，死因分别为服用免疫抑制剂依从性差2例，移植心脏衰竭、排斥反应和肝功能衰竭1例。死亡组和存活组受者手术时年龄、体质指数、左室射血分数、原发病以及术前接受心肺复苏、血管活性药物维持和ECMO过渡等基线情况差异均无统计学意义(P均>0.05)。死亡组和存活组对应供者年龄、体质量差、供心冷缺血时间、脑死亡原因构成、供/受者性别和ABO血型匹配以及边缘供心比例差异均无统计学意义(P均>0.05)，死亡组供/受者年龄差过大(>17岁)的比例高于存活组(P<0.05)。死亡组和存活组受者体外循环时间中位数分别为201(185，226)和170(152，197)min，术中浓缩红细胞用量分别为8.0(5.5，9.0)和4.0(2.0，6.0)U，血小板用量分别为4.0(2.0，6.0)和2.0(2.0，2.0) U，差异均有统计学意义(Z＝4.494、5.305和7.418，P均<0.05)。死亡组受者ICU停留时间和术后呼吸机使用时间长于存活组，分别为11.1(5.9，17.7)和3.8(2.9-5.0)d，58(12，172)和8(6，15) h(Z＝14.817和7.335，P均<0.05)；同时，死亡组长时间停留ICU(停留时间>5 d)和长时间使用呼吸机(使用时间>24 h)的受者比例高于存活组，差异均有统计学意义(P均<0.05)。74例受者总体1、3和5年生存率分别为91.9%、84.7%和74.1%。将两组受者术前和术中指标以及对应供者指标差异有统计学意义的因素纳入Cox比例风险模型分析，结果显示术中血小板用量是心脏移植术后死亡的独立危险因素，术中使用血小板每增加1 U，术后死亡风险增加1.35倍(HR＝2.35，95% CI 1.28~4.32，P<0.05)。

心脏移植术后结局受多种因素影响，术中红细胞和血小板用量及供/受体年龄差过大是心脏移植术后死亡的危险因素。

A retrospective analysis of 7 patients who died after heart transplantation in a single center, and to explore the risk factors for death after heart transplantation.

From May 1, 2015 to May 1, 2019, 74 cases of orthotopic heart transplantation were performed in the Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University. By April 2020, with a follow-up time of 724 days, 65 recipients survived and 9 died. Two cases of death due to non-medical causes were excluded, and the recipients were divided into survival group (65 cases) and death group (7 cases). Preoperative, intraoperative, and postoperative parameters and corresponding donor conditions were collected for the survival group. Continuous variables that met the normal distribution were compared using the t-test, and continuous variables that were not normally distributed were analyzed using the Kruskal-Wallis test. Enumeration data were compared using Fisher′s exact test. Survival curves were plotted using the Kaplan-Meier method. Cox proportional hazards models were used to analyze risk factors for death after heart transplantation.

Of the 7 dead recipients, 4 died of transplant heart failure, rejection, respiratory failure and other organ failure during hospitalization, including 1 recipient of combined heart-lung transplantation and 3 recipients who died during follow-up: 2 cases with poor compliance with immunosuppressive agents, 1 case with transplant heart failure, rejection and liver failure. There were no significant differences in age at operation, body mass index, left ventricular ejection fraction, primary disease, preoperative cardiopulmonary resuscitation, vasoactive drug maintenance and ECMO transition between the surviving recipients (P>0.05). There were no significant differences in donor age, poor body weight, donor cold ischemia time, cause of brain death, donor/recipient sex and ABO blood group matching, and marginal donor ratio in the death and survival groups (P>0.05), and the proportion of donor/recipient age difference (>17 years) in the death group was higher than that in the survival group (P<0.05). The median cardiopulmonary bypass time was 201 (185, 226) and 170 (152, 197) min, the intraoperative packed red blood cell dosage was 8.0 (5.5, 9.0) and 4.0 (2.0, 6.0) U, and the platelet dosage was 4.0 (2.0, 6.0) and 2.0 (2.0, 2.0) U in the surviving recipients, and the differences were statistically significant (P<0.05). The ICU stay and postoperative ventilator use time of recipients in the death group were longer than those in the survival group, 11.1 (5.9, 17.7) and 3.8 (2.9-5.0) d, 58 (12, 172) and 8 (6, 15) h, respectively; meanwhile, the proportion of recipients who stayed in the ICU (stay >5 d) and used the ventilator for a long time (use > 24 h) in the death group was higher than that in the survival group, and the differences were statistically significant (P<0.05 for all). The 1-, 3-, and 5-year overall survival rates of the 74 recipients were 91.9%, 84.7%, and 74.1%, respectively. The factors with statistically significant differences in preoperative and intraoperative indicators and corresponding donor indicators between the two groups were included in Cox proportional hazards model analysis. The results showed that intraoperative platelet dosage was an independent risk factor for death after heart transplantation. For every U increase in intraoperative platelet use, the risk of postoperative death increased by 1.35 times (HR=2.35, 95% CI 1.28~4.32, P<0.05).

The outcome after heart transplantation is influenced by many factors. Excessive differences in intraoperative red blood cell and platelet dosage and donor/recipient age are risk factors for death after heart transplantation.