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中华移植杂志(电子版)

中华移植杂志(电子版) ›› 2022, Vol. 16 ›› Issue (05) : 277 -284. doi: 10.3877/cma.j.issn.1674-3903.2022.05.003

论著

主动脉内球囊反搏作为心脏移植桥接治疗对晚期心力衰竭合并肺动脉高压患者的疗效
郑珊珊1, 郑哲1, 黄洁2, 廖中凯2, 宋云虎1, 房晓楠2, 刘盛1,†()   
  1. 1. 100037　北京，中国医学科学院阜外医院心脏外科
    2. 100037　北京，中国医学科学院阜外医院心力衰竭与移植病房
  • 收稿日期:2022-06-23 出版日期:2022-10-25
  • 通信作者: 刘盛
  • 基金资助:
    国家重点研发计划项目(2016YFC1300900)

Efficacy of intra-aortic balloon pump as bridging therapy for heart transplantation in patients with advanced heart failure and pulmonary hypertension

Shanshan Zheng1, Zhe Zheng1, Jie Huang2, Zhongkai Liao2, Yunhu Song1, Xiaonan Fang2, Sheng Liu1,†()   

  1. 1. Department of Cardiac Surgery, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100037, China
    2. Department of Heart Failure and Heart Transplant, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing 100037, China
  • Received:2022-06-23 Published:2022-10-25
  • Corresponding author: Sheng Liu
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引用本文：

郑珊珊, 郑哲, 黄洁, 廖中凯, 宋云虎, 房晓楠, 刘盛. 主动脉内球囊反搏作为心脏移植桥接治疗对晚期心力衰竭合并肺动脉高压患者的疗效[J]. 中华移植杂志(电子版), 2022, 16(05): 277-284.

Shanshan Zheng, Zhe Zheng, Jie Huang, Zhongkai Liao, Yunhu Song, Xiaonan Fang, Sheng Liu. Efficacy of intra-aortic balloon pump as bridging therapy for heart transplantation in patients with advanced heart failure and pulmonary hypertension[J]. Chinese Journal of Transplantation(Electronic Edition), 2022, 16(05): 277-284.

目的

分析主动脉内球囊反搏(IABP)作为心脏移植桥接治疗对晚期心力衰竭合并肺动脉高压(PH)患者的疗效。

方法

回顾性分析2015年1月至2020年12月在中国医学科学院阜外医院接受心脏移植的478例受者资料，根据术前是否合并PH分为无PH组(221例)和PH组(257例)；PH组受者根据术前是否通过IABP桥接至心脏移植分为IABP支持组(50例)和无IABP支持组(207例)。比较3组受者左心室射血分数(LVEF)、左心房直径(LAD)和左心室舒张末期直径(LVEDD)等超声心动图指标，以及肺动脉收缩压(SPAP)、肺动脉舒张压(DPAP)、平均肺动脉压(MPAP)、肺血管阻力(PVR)、肺毛细血管楔压(PCWP)和心输出量(CO)等血流动力学数据。比较IABP支持前后血流动力学和实验室检查指标的变化，同时使用不包括国际标准化比值的改良终末期肝病模型(MELD-XI)评分来评估受者肝肾功能的改善情况。观察受者院内结局以及长期生存情况。

结果

IABP支持的PH组受者术前血清肌酐为107.2(87.3, 131.0)μmol/L，显著高于其他2组(H＝6.5和2.5，P均<0.05)；术前评估心脏移植指征时首次Swan-Ganz漂浮导管测量的SPAP、DPAP和MPAP分别为(52±17)、(27±9)和(36±10)mmHg，PVR为(3.5±1.8)Wood单位，均高于无PH组和无IABP支持的PH组(P均<0.05)。三组受者年龄、性别、原发病、既往病史、术前心脏植入式电子装置植入史、心功能分级、超声心动图指标、静脉血管活性药物应用、群体反应性抗体以及供者和供心指标等差异均无统计学意义(P均>0.05)。与IABP支持前相比，IABP支持后SPAP、MPAP、DPAP、PCWP、LAD和LVEDD均下降(t＝6.4、6.1、5.2、6.0、3.9和2.3，P均<0.05)，CO和收缩压均增加(t＝－2.6和－4.6，P均<0.05)；N端脑利钠肽原和血清总胆红素水平均降低(Z＝－3.7和－2.5，P均<0.05)。此外，IABP支持后MELD-XI评分下降(t＝3.2，P<0.05)。心脏移植术后住院期间，无PH组、IABP支持的PH组以及无IABP支持的PH组受者院内死亡率分别为4.1%(9/221)、8.0%(4/50)和2.9%(6/207)，差异无统计学意义(χ2＝2.8，P>0.05)。无PH组、IABP支持的PH组以及无IABP支持的PH组术后IABP置入率分别为19.5%(43/221)、58.0%(29/50)和13.0%(27/207)，差异有统计学意义(χ2＝50.0，P<0.05)。与无PH组和无IABP支持的PH相比，IABP支持的PH组ICU住院时间和总住院时间均延长(H＝92.2和88.8，以及84.1和82.7，P均<0.05)。无PH组、IABP支持的PH组以及无IABP支持的PH组1年生存率分别为95.0%、92.0%和95.2%，3年生存率分别为92.6%、92.0%和91.1%，5年生存率分别为90.1%、92.0%和89.5%，差异均无统计学意义(P均>0.05)。

结论

IABP支持可作为心脏移植桥接治疗，有助于合并严重PH的终末期心力衰竭患者成功过渡至移植候选队列，并降低心脏移植的风险。

关键词: 心脏移植, 终末期心力衰竭, 肺动脉高压, 主动脉内球囊反搏
Objective

To analyze the efficacy of intra-aortic balloon pump (IABP) as a bridging therapy for heart transplantation in patients with advanced heart failure and pulmonary hypertension (PH).

Methods

The clinical data of 478 recipients who received heart transplantation in Fuwai Hospital, Chinese Academy of Medical Sciences from January 2015 to December 2020 were retrospectively analyzed. The patients were divided into non-PH group (221 cases), IABP support PH group (50 cases) and non-IABP support PH group (207 cases) according to preoperative IABP bridging to heart transplantation. Echocardiographic parameters such as left ventricular ejection fraction (LVEF), left atrial diameter (LAD) and left ventricular end-diastolic diameter (LVEDD), as well as hemodynamic data such as systolic pulmonary artery pressure (SPAP), diastolic pulmonary artery pressure (DPAP), mean pulmonary artery pressure (MPAP), pulmonary vascular resistance (PVR), pulmonary capillary wedge pressure (PCWP) and cardiac output (CO) were compared among the three groups. Changes in hemodynamic and laboratory parameters before and after IABP support were compared, the modified model for end-stage liver disease excluding the international normalized ratio (MELD-XI) score was used to assess improvement in liver and kidney function in recipients. We also observed in-hospital outcomes and long-term survival of recipients.

Results

The preoperative serum creatinine of IABP support PH group was 107.2 (87.3, 131.0) μmol/L, which was significantly higher than that of the other two groups (H=6.5 and 2.5, P<0.05 for all); the SPAP, DPAP and MPAP measured at the preoperative evaluation of heart transplantation were (52±17), (27±9) and (36±10) mmHg, respectively, and the PVR was (3.5±1.8) Wood units (WU), which were higher than those of the other two groups (P<0.05 for all). There were no significant differences in recipient age, sex, primary diseases, preoperative cardiac implantable electronic device implantation history, cardiac functional classification, echocardiographic parameters, intravenous vasoactive drug application, panel reactive antibodies, and donor and donor heart parameters among the three groups (P>0.05 for all). After IABP support, SPAP, MPAP, DPAP, PCWP, LAD and LVEDD were decreased (t=6.4, 6.1, 5.2, 6.0, 3.9 and 2.3, P<0.05 for all), CO and systolic blood pressure were increased (t=-2.6 and -4.6, P<0.05 for all); N-terminal pro-brain natriuretic peptide and serum total bilirubin levels were decreased (Z=-3.7 and -2.5, P<0.05 for all). In addition, MELD-XI scores were decreased after IABP support (t=3.2, P<0.05). During hospitalization after heart transplantation, in-hospital mortality was 4.1% (9/221), 8.0% (4/50), and 2.9% (6/207) in the non-PH group, IABP support PH group and non-IABP support PH group, respectively, and the difference was not statistically significant (χ2=2.8, P>0.05). The postoperative IABP placement rates were 19.5% (43/221), 58.0% (29/50), and 13.0% (27/207) in the non-PH group, IABP support PH group and non-IABP support PH group, respectively, and the differences were statistically significant (P<0.05). Compared with the non-PH group and the non-IABP support PH group, the ICU length of stay and total length of stay were prolonged in the IABP support PH group (H=92.2, 88.2, 84.1 and 82.7, P<0.05 for all). The 1-year survival rate was 95.0%, 92.0% and 95.2%, the 3-year survival rate was 92.6%, 92.0% and 91.1%, and the 5-year survival rate was 90.1%, 92.0% and 89.5% in the non-PH group, IABP support PH group and non-IABP support PH group, respectively, and the differences were not statistically significant (P>0.05 for all).

Conclusion

IABP support can be used as a bridge to heart transplantation, which helps end-stage heart failure patients with severe PH to successfully transition to the transplant candidate cohort and reduce the risk of heart transplantation.

Key words: Heart transplantation, Advance heart failure, Pulmonary hypertension, Intra-aortic balloon pump
表1 合并与未合并PH的心脏移植受者术前评估基线资料比较
变量 无PH组(n＝221) IABP支持的PH组(n＝50) 无IABP支持的PH组(n＝207) F/H/χ2值 P值
年龄(岁，±s) 49±12 47±12 46±12 2.8 >0.05
体质量指数(kg/m2，±s) 22± 3 22± 4 22± 4 1.1 >0.05
性别[n(%)]          
  男 162 (73.3) 42 (84.0) 155 (74.9) 2.5 >0.05
  女 59 (26.7) 8 (16.0) 52 (25.1)    
高血压史[n(%)] 10 ( 4.5) 2 ( 4.0) 11 ( 5.3) 0.2 >0.05
吸烟史[n(%)] 56 (25.3) 7 (14.0) 47 (22.7) 3.0 >0.05
糖尿病史[n(%)] 43 (19.5) 9 (18.0) 33 (15.9) 0.9 >0.05
术前植入ICD/CRT/CRT-D[n(%)] 61 (27.6) 10 (20.0) 43 (20.8) 3.2 >0.05
既往心脏手术史[n(%)] 38 (17.2) 12 (24.0) 40 (19.3) 1.3 >0.05
NYHA心功能分级[n(%)]       4.4 >0.05
  III级 61 (27.6) 11 (22.0) 59 (28.5)    
  IV级 160 (72.4) 39 (78.0) 148 (71.5)    
LVEF (%) 30±10 27± 6 30±11 1.8 >0.05
LVEDD (mm，±s) 68±14 72±12 69±15 2.3 >0.05
SPAP (mmHg，±s) 30±11 52±17 46±12 123.3 <0.05
DPAP (mmHg，±s) 14± 7 26± 9 23± 6 120.2 <0.05
MPAP (mmHg，±s) 18± 5 36±10 33±10 361.0 <0.05
PVR (WU，±s) 2.5±1.7 3.5±1.8 3.1±1.9 7.8 <0.05
血清总胆红素[μmol/L，M(P25，P75)] 24.1(14.9, 34.2) 21.0(12.0, 31.4) 22.7(16.7, 37.1) 1.4 >0.05
血清肌酐[μmol/L，M(P25，P75)] 95.6(80.2, 123.0) 107.2(87.3, 131.0) 88.5(74.8, 108.2) 17.9 <0.05
静脉血管活性药物支持[n(%)] 174 (78.7) 43 (86.0) 173 (83.6) 2.4 >0.05
原发病[n(%)]       22.3 >0.05
  扩张型心肌病 116 (52.5) 33 (66.0) 116 (56.0)    
  缺血性心肌病 34 (15.4) 9 (18.0) 23 (11.1)    
  肥厚型心肌病 18 ( 8.1) 2 ( 4.0) 10 ( 4.8)    
  限制型心肌病 6 ( 2.7) 1 ( 2.0) 11 ( 5.3)    
  致心律失常性右心室心肌病 17 ( 7.7) 0 ( 0.0) 10 ( 4.8)    
  瓣膜病 12 ( 5.4) 0 ( 0.0) 10 ( 4.8)    
  其他a 18 ( 8.1) 5 (10.0) 9 ( 4.3)    
术前PRA阳性[n(%)] 25 (11.3) 5 (10.0) 29 (14.0) 1.0 >0.05
供者年龄(岁，±s) 36.±11 38±11 35±11 1.6 >0.05
供者性别[n(%)]          
  男 200 (90.5) 48 (96.0) 194 (93.7) 2.6 >0.05
  女 21 ( 9.5) 2 ( 4.0) 13 ( 6.3)    
供者体质量(kg，±s) 69±11 68±11 69±11 0.1 >0.05
供心冷缺血时间(min，±s) 271±98 266±95 287±105 1.7 >0.05
表2 31例合并PH的心脏移植受者IABP支持前后血流动力学和实验室检查指标变化*
变量 IABP支持前 IABP支持后 t/Z/χ2值 P值
收缩压(mmHg，±s) 92±13 104±13 －4.6 <0.05
舒张压(mmHg，±s) 64±11 65±11 －0.6 >0.05
实验室检查指标        
  NT-proBNP[μmol/L，M(P25，P75)] 8198.5(3 952.0, 21 682.3) 3150.0(1 240.6, 7 440.8) －3.7 <0.05
  血尿素氮(μmol/L，±s) 11.9±5.8 9.7±5.3 1.8 >0.05
  血清肌酐[μmol/L，M(P25，P75)] 115.8(102.3, 134.1) 116.2(89.4，136.0) －1.3 >0.05
  血清总胆红素[μmol/L，M(P25，P75)] 32.4(20.0, 49.9) 20.6(10.7, 36.1) －2.5 <0.05
MELD-XI评分(分，±s) 16± 8 13± 8 3.2 <0.05
超声心动图指标        
  LVEF(%，±s) 27± 7 28± 6 －1.3 >0.05
  LAD(mm，±s) 52± 8 49± 8 3.9 <0.05
  LVEDD(mm，±s) 74±11 72±10 2.3 <0.05
  中度及以上二尖瓣返流[n(%)] 25 (80.6) 20 (64.5) 2.0 >0.05
  中度及以上三尖瓣返流[n(%)] 17 (54.8) 11 (35.4) 2.3 >0.05
血流动力学指标        
  SPAP(mmHg，±s) 59±10 43±11 6.4 <0.05
  MPAP(mmHg，±s) 40± 7 29± 8 6.1 <0.05
  DPAP(mmHg，±s) 29± 7 18± 8 5.2 <0.05
  CO(L/min，±s) 3.3±1.2 3.8±0.9 －2.6 <0.05
  PCWP(mmHg，±s) 26±10 15± 8 6.0 <0.05
  PVR(WU，±s) 3.3±2.0 2.9±1.7 1.1 >0.05
表3 无PH组、IABP支持的PH组和无IABP支持的PH组心脏移植受者住院期间相关指标比较
变量 无PH组(n＝221) IABP支持的PH组(n＝50) 无IABP支持的PH组(n＝207) F/H/χ2值 P值
ICU住院时间[d，M(P25, P75)] 4.5 ( 3.4, 6.0) 6.7 ( 4.4, 11.7) 4.5 ( 2.9, 5.9) 19.3 <0.05
术后机械通气时间[h，M(P25, P75)] 25.5 (19.0, 39.0) 23.0 (18.0, 41.0) 27.0 (18.0, 41.0) 0.1 >0.05
术后使用CRRT[n(%)] 9 ( 4.1) 2 ( 4.0) 5 ( 2.4) 1.0 >0.05
术后使用IABP支持[n(%)] 43 (19.5) 29 (58.0) 27 (13.0) 50.0 <0.05
术后使用ECMO支持[n(%)] 16 ( 7.2) 0 ( 0.0) 13 ( 6.3) 3.8 >0.05
术后感染[n(%)] 14 ( 6.3) 4 ( 8.0) 7 ( 3.4) 2.7 >0.05
术后再次开胸止血[n(%)] 10 ( 4.5) 4 ( 8.0) 10 ( 4.8) 1.1 >0.05
术后总住院时间[d，M(P25, P75)] 16.0 (14.0, 21.0) 22.0 (17.0, 34.0) 16.0 (14.0, 23.0) 16.7 <0.01
院内死亡[n(，%)] 9 ( 4.1) 4 ( 8.0) 6 ( 2.9) 2.8 >0.05
图1 无PH组、IABP支持的PH组以及无IABP支持的PH组心脏移植受者术后生存曲线注：PH.肺动脉高压；IABP.主动脉内球囊反搏
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