心脏移植患者术前肺动脉压力与术后并发症的关系及防治

The Relation Between Preoperative Pulmonary Artery Pressure and Postoperative Complications in Heart Transplantation Patients and the Prevention and Treatment to Postoperative Complications

目的分析心脏移植患者术前肺动脉压力和肺血管阻力（PVR）与术后右心功能不全、并发症发生和死亡的关系,总结围术期肺动脉高压的管理经验,以利于心脏移植术后患者早期心功能的恢复。方法125例接受同种原位心脏移植手术的患者,根据术前肺动脉收缩压（PASP）和PVR不同分为两组,肺动脉高压组（n=56）：术前PASP〉50 mm Hg或PVR〉5 Wood.U;对照组（n=69）：术前PASP≤50 mm Hg,PVR≤5 Wood.U。通过Swan-Ganz导管监测两组手术前心脏排血指数（CI）,手术前。

Objective To analyze the relation between preoperative pulmonary artery pressure （PAP） and postoperative complications in heart transplant patients, and summarize the experience of perioperative management of pulmonary hypertension （PH）, to facilitate the early period heart function recovery of postoperative heart transplant patients. Methods A total of 125 orthotopic heart transplant patients were divided into two groups according to preoperative pulmonary arterial systolic pressure （PASP） and pulmonary vascular resistance （PVR）, pulmonary hypertension group （n=56）： preoperative PASP〉50mmHg or PVR〉5 Wood-U; control group （n=69）：preoperative PASP≤50 mmHg and PVR≤5 Wood · U. Hemodynamics index including preoperative cardiac index （CI） ,preoperative and postoperative PVR and PAP were collected by Swan-Ganz catheter and compared. The extent of postoperative tricuspid regurgitation was evaluated by echocardiography. Postoperative pulmonary hypertension was treated by diuresis, nitrogen oxide inhaling, nitroglycerin and prostacyclin infusion, continuous renal replacement therapy（CRRT） and extracorporeal membrane oxygenation （ECMO）. Results All patients survived except one patient in pulmonary hypertension group died of multi-organ failure and severe infection postoperatively in hospital. Acute right ventricular failure occurred postoperatively in 23 patients, 10 patients used ECMO support, 10 patients with acute renal insufficiency were treated with CRRT. 124 patients were followed up for 2 59 months, 7 patients died of multiple organ failure, infection and acute rejection in follow-up period, the survivals in both groups have normal PAP, no significant tricuspid regurgitation. No significant difference in cold ischemia time of donor heart, cardiopulmonary bypass（CPB） and circulation support time between both groups; but the patients of pulmonary hypertension group had longer tracheal intubation time in comparison with the patients of control group （65± 119 h vs. 32± 38 h, t= 2.17, P= 0. 028）. Preoperative PASP,mean pulmonary artery pressure（MPAP） and PVR in pulmonary hypertension group were significantly higher than those in control group, CI was lower in pulmonary hypertension group [PASP 64.30±11.50 mm Hg vs. 35.60±10.20 mm Hg; MPAP 43.20±8.50 mm Hg vs. 24.20±7.20 mm Hg＇ PVR 4. 72±2. 26 Wood · Uvs. 2.27±1.24 Wood· U; CI1.93±0.62 L/（min ·m2） vs. 2.33±0.56 L/（min. m2）; P〈0. 05]. Postoperative early PASP, MPAP and PVR in pulmonary hypertension group were significantly higher than those in control group （PASP 35.40±5.60 mm Hg vs. 31.10±5.70 mm Hg, MPAP 23. 10±3.60 mm Hg vs. 21.00_±4.00 mm Hg, PVR 2. 46±0. 78 Wood· U vs. 1. 79±0.62 Wood · U; P〈0.05）. Conclusion Postoperative right heart insuficiency is related to preoperative pulmonary hypertension in heart transplant patients. Donor heart can quickly rehabilitate postoperatively by effectively controlling perioperative pulmonary hypertension with good follow up results.