供受者预测心脏质量对成人心脏移植近中期预后的影响

Impact of donor-recipient predicted heart mass on short to mid-term prognosis after adult heart transplantation

目的探讨供受者预测心脏质量(PHM)匹配对成人(≥18岁)心脏移植术后近中期预后的影响。方法回顾性分析2015年1月至2019年12月在华中科技大学同济医学院附属协和医院心脏大血管外科接受原位心脏移植的成人受者临床资料。供受者PHM相对差异>15%纳入供心过小组;供受者PHM相对差异绝对值≤15%纳入供心匹配组;供受者PHM相对差异<-15%纳入供心过大组。观察和比较供心过大组、匹配组和过小组间基线资料、供受者匹配资料、围手术期资料和心脏移植术后近中期预后情况。采用Kruskal-Wallis H检验比较三组间非正态分布计量资料。采用卡方检验或Fisher确切概率法比较三组间计数资料。采用Spearman秩相关分析法分析供受者PHM相对差异与供受者身高和体质量相对差异相关性。采用Kaplan-Meier法绘制三组受者术后1年生存曲线并采用log-rank检验进行比较。采用单因素Cox比例风险模型评估供受者PHM匹配类型和协变量与移植后1年死亡风险的关联。P<0.05为差异有统计学意义。结果最终纳入409例心脏移植受者,其中供心过小组57例,供心匹配组248例,供心过大组104例。三组供受者性别以及受者身高、体质量、血红蛋白、血清肌酐、左心房内径和左心室内径差异均有统计学意义(χ^(2)=70.396和124.77,H=95.609、127.251、20.551、10.557、10.048和16.829,P均<0.05)。三组供受者PHM相对差异、体质量相对差异、身高相对差异及供受者性别匹配差异均有统计学意义(H=309.231、198.337和175.310,χ^(2)=288.827,P均<0.05)。供受者PHM相对差异与供受者体质量和身高相对差异均显著相关(r=0.863和0.720,P均<0.05)。三组受者术后IABP使用比例和呼吸系统并发症发生率以及术后3周左心房和右心房内径差异均有统计学意义(χ^(2)=6.619和6.313,H=12.915和10.727,P均<0.05)。供心过大组、供心匹配组和供心过小组受者术后1年累积生存率分别为84.6%、84.5%和93.0%,差异无统计学意义(χ^(2)=2.998,P>0.05)。Cox比例风险模型单因素分析结果表明,受者术前血红蛋白、血清肌酐、左心室内径和年龄是受者术后1年死亡影响因素(HR=0.980、1.004、0.831和1.036,P均<0.05);Cox比例风险模型多因素分析结果显示受者术前血红蛋白和左心室内径均为受者术后1年死亡的独立保护因素(HR=0.982和0.839,P均<0.05),受者年龄和术前总胆红素均为独立危险因素(HR=1.048和1.017,P均<0.05)。结论心脏移植供受者PHM匹配对受者术后1年生存率无显著影响,受者术前血红蛋白和左心室内径是其术后1年死亡的独立保护因素,年龄和总胆红素是其术后1年死亡的独立危险因素。

Objective To exploring the impact of donor-recipient predicted heart mass(PHM)matching on short to mid-term prognosis of adult(≥18 years old)heart transplantation.Methods The clinical data of adult patients who received orthotopic heart transplantation in the Department of Cardiovascular Surgery,Union Hospital,Tongji Medical College,Huazhong University of Science and Technology from 2015 to 2019 were retrospectively analyzed.The recipients whose donor-recipient PHM relative differences were greater than 15%,were classified into the oversized group;those whose donor-recipient PHM relative differences were less than-15%,were classified into the undersized group;the others whose absolute value of donor-recipient PHM relative differences were within 15%,were classified into the matched group.The baseline data,perioperative data,matching data of donor and recipient,perioperative data and prognosis among the three groups were compared.The non-normal distribution measurement data among the three groups were compared by Kruskal-Wallis H test.The enumeration data among the three groups were compared by chi-square test or Fisher′s exact probability method.The Spearman rank correlation analysis method was used to analyse the correlation between PHM relative difference and height or weight relative difference.The Kaplan-Meier method was used to draw the postoperative 1-year survival curve of the three groups and the postoperative 1-year survival rate among the three groups was compared with log-rank test.Univariate and multivariate Cox proportional hazards model was used to evaluate the association between different PHM types and covariates and the risk of death at 1 year after transplantation.P<0.05 was considered statistically significant.Results Four hundred and nine heart transplantation recipients were included,of which 57 were in the donor undersized group,248 were in the donor matched group,and 104 were in the donor oversized group.The difference of gender of donors and recipients,and height,weight,preoperative hemoglobin,preoperative serum creatinine,left atrial diameter and left ventricular internal diameter of recipients among the three groups were statistically significant(χ^(2)=70.396 and 124.77,H=95.609,127.251,20.551,10.557,10.048 and 16.829,all P<0.05).The difference of relative difference in PHM,weight,height,donor-recipient gender matching among the three groups were statistically significant(H=309.231,198.337 and 175.310,χ^(2)=288.827,P all<0.05).The relative difference in PHM was significantly related to the relative difference in weight and height(r=0.863 and 0.720,all P<0.05).The difference of postoperative IABP usage rate,incidience of respiratory complications,left atrial and right atrium diameter of recipients among the three groups were statistical difference significant(χ^(2)=6.619 and 6.313,H=12.915 and 10.727,all P<0.05).The 1-year cumulative survival rates of the donor oversized group,the matched group,and the donor undersized group were 84.6%,84.5%,and 93%,respectively,which were not statistically significant(χ^(2)=2.998,P>0.05).The results of univariate Cox proportional hazards model showed that preoperative hemoglobin,serum creatinine,left ventricular internal diameter and age of recipients had strong effect on 1 year death rate(HR=0.980,1.004,0.831 and 1.036,all P<0.05).The results of multivariate Cox proportional hazards model showed that preoperative hemoglobin and left ventricular internal diameter of recipients were the independent protective factors for 1 year death rate(HR=0.982 and 0.839,all P<0.05),and the age and preoperative total bilirubin were the independent risk factors(HR=1.048 and 1.017,all P<0.05).Conclusions The different type of donor-recipient PHM matching has no significant effect on the 1 year death rate after heart transplantation,and preoperative hemoglobin and left ventricular internal diameter were the independent protective factors for 1 year death rate,and age and total bilirubin of recipients were the independent risk factors for 1 year death rate.