探究体外膜肺氧合(ECMO)循环辅助在心脏移植前桥接治疗中的作用及临床结局。

回顾性分析2019年3月至2022年8月在浙江大学医学院附属第一医院心脏大血管外科接受心脏移植的96例受者临床资料，根据术前是否接受ECMO循环辅助，将其分为ECMO组(n＝33)和非ECMO组(n＝63)。呈正态分布计量资料采用成组t检验进行比较，非正态分布的计量资料采用Mann-Whitney U检验进行比较，计数资料采用卡方检验进行比较。采用Kaplan-Meier法绘制生存曲线并采用log-rank检验进行比较。P<0.05为差异有统计学意义。

ECMO组受者术前ECMO辅助时间为9.29(3.23，20.81)d，其中6例术前行房间隔造瘘。ECMO组和非ECMO组受者等待移植时间、C反应蛋白、极低密度脂蛋白、高密度脂蛋白、尿酸、AST、ALT、总胆红素、心肺复苏史、起搏器植入情况、既往心脏手术史及心脏原发病情况差异均有统计学意义(Z＝438.50、1 564.00、900.00、109.00、1 583.50和1 556.50, t＝2.28和1 157.50, χ²＝32.29、6.10、9.87和18.24，P均<0.05)。两组受者冷缺血时间、体外循环时间、阻断时间、术中红细胞输注量、术中血浆输注量、ICU住院时间、机械通气时间和术后ECMO使用情况差异均有统计学意义(Z＝1 405.5、1 235.5、1 437.5、1 192.5、981.0、1 567.5和1 587.0, χ²＝28.46，P均<0.05)。ECMO组中19例(57.6%)受者术后继续行ECMO循环辅助，比例高于非ECMO组[5例(7.9%)]，差异有统计学意义(χ²＝28.46，P<0.05)。ECMO组术后30 d内5例(15.2%)受者死亡，非ECMO组2例(3.2%)受者死亡，差异有统计学意义(χ²＝4.595，P<0.05)。ECMO组7例(21.2%)受者发生院内死亡，非ECMO组4例(6.3%)受者发生院内死亡，差异有统计学意义(χ²＝4.715，P<0.05)。ECMO组术后1年内10例(30.3%)受者死亡，非ECMO组7例(11.1%)死亡，差异有统计学意义(χ²＝5.474，P<0.05)。ECMO组与非ECMO组受者累积生存率差异有统计学意义(χ²＝4.650，P<0.05)。若剔除术后30 d内死亡受者，两组受者术后累积生存率差异无统计学意义(χ²＝1.140，P>0.05)。

ECMO桥接心脏移植受者总体预后虽劣于无移植前桥接受者，但通过加强围术期的评估、管理和个体化治疗，可进一步提高ECMO桥接心脏移植受者远期预后。

To evaluate the role and clinical outcome of extracorporeal membrane oxygenation (ECMO) as circulatory support bridging to heart transplantation.

The clinical data of 96 recipients who underwent heart transplantation in the Department of Cardiovascular Surgery, the First Affiliated Hospital, College of Medicine, Zhejiang University from March 1st, 2019 to August 31, 2022 were retrospectively analyzed. All 96 recipients were divided into the ECMO group (n=33) and the non-ECMO group (n=63) based on whether received ECMO as circulatory support. To compare continuous variables between groups, the unpaired Student′s t-test was used if the continuous data were normally distributed, while the Mann-Whitney U test was used when the continuous data were non-normally distributed. Chi-square test was used to compare categorical variables. Kaplan-Meier survival analysis was performed to make survival curves and were compared by using log-rank test. P<0.05 was considered statistically significant.

The circulatory support time in the ECMO group was 9.29 (3.23, 20.81) d and 6 recipients in the ECMO group also received percutaneous balloon atrial septostomy. There were statistical difference for the indexes of recipients including the waiting-list time, C-reactive protein, very-low-density lipoprotein, high-density lipoprotein, uric acid, AST, ALT, total bilirubin, history of cardiopulmonary resuscitation, history of pacemaker implantation, history of cardiac surgery and primary heart disease between the two groups (Z=438.50, 1 564.00, 900.00, 109.00, 1 583.50 and 1 556.50, t=2.28 and 1 157.50, χ²=32.29, 6.10, 9.87 and 18.24, all P<0.05). Moreover, the indexes including the cold ischemic time, cardiopulmonary bypass time, aortic clamping time, intraoperative red blood cell transfusion, intraoperative plasma infusion, intensive care unit stay time, mechanical ventilation time and postoperative ECMO application of recipients were statistically different between the two groups (Z=1 405.5, 1 235.5, 1 437.5, 1 192.5, 981.0, 1 567.5 and 1 587.0, χ²=28.46, all P<0.05). There were 19 recipients (57.6%) received ECMO postoperatively, which was statistically higher than that in the non-ECMO group (5 cases, 7.9%) (χ²=28.46, P<0.05). Compared with the non-ECMO group, the ECMO group had higher 30-day mortality (15.2% vs 3.2%, χ²=4.595, P<0.05), higher in-hospital mortality (21.2% vs 6.3%, χ²=4.715, P<0.05) and higher 1-year mortality (30.3% vs 11.1%, χ²=5.474, P<0.05). There was statistical difference for the cumulative survival rate between the ECMO group and the non-ECMO group (χ²=4.650, P<0.05). After excluding the death cases within 30 days after transplantation, there was no significant difference for the cumulative survival rate between the two groups (χ²=1.140, P>0.05).

Although the overall prognosis patients with ECMO bridged heart transplantation recipients is worse than that of non-bridged recipients, it is still an effective treatment for patients with irreversible cardiogenic shock. Effective preoperative evaluation, well perioperative management and individualized postoperative anti-rejection treatment can further improve the long-term prognosis of ECMO bridged heart transplantation.