老龄原位心脏移植受者的特点、预后及其相关影响因素单中心分析

Characteristics,outcomes and its relative risk factors in elderly recipients of heart transplantation:a single-center experience

目的探讨老龄心脏移植受者的数量变化趋势和预后情况,并对相关危险因素进行分析。方法回顾性分析2004年6月至2021年12月在中国医学科学院阜外医院进行心脏移植的1044例年龄≥18岁受者的临床资料及年龄分布情况。根据心脏移植时受者年龄是否大于60岁,分为老龄组(≥60岁,877例)和非老龄组(<60岁,157例),再将老龄组受者按<65岁(107例)及≥65岁(50例)进行亚组分析,分别比较上述各组供者的基线资料及受者的基线资料、临床资料、术后院内及术后1年病死率和远期生存率。进一步分析非老龄组、老龄组中<65岁和老龄组中≥65岁受者的远期生存差异。采用logistic回归模型和Cox比例风险回归模型分析全部纳入研究受者心脏移植术后短期病死率和累积生存率的相关危险因素。采用Kaplan-Meier法绘制生存曲线,比较采用Log-rank检验。采用多变量logistic回归模型对短期病死率的相关危险因素进行分析,采用多变量Cox比例风险回归模型对累积生存率的相关危险因素进行分析,在校正其他混杂因素的前提下,以确定受者年龄对心脏移植术后生存的影响。结果本中心每年接受移植手术的老龄受者例数均有所增加,而成年心脏移植受者的平均年龄及老龄受者的平均年龄相对稳定。本研究的中位随访时间为6.5年。基线资料方面,老龄组受者与非老龄组男性[84.7%(113/157)比77.5%(687/877)],有高血压[20.4%(32/157)比8.9%(79/877)]、吸烟[47.1%(74/157)比36.1%(320/877)]、糖尿病史[33.8%(53/157)比14.7%(130/877)],术前植入转复除颤器/心脏再同步化治疗起搏器/心脏再同步化治疗除颤器(ICD/CRT/CRT-D)比例[28.0%(44/157)比18.0%(160/877)]和术前肌酐[(105.3±25.3)μmol/L比(96.8±35.0)μmol/L]、IMPACT评分[(6.9±2.4)分比(4.2±2.9)分]、血清总胆红素[19.7(13.6,30.3)μmol/L比23.7(15.8,36.8)μmol/L]、平均肺动脉压[(26.0±10.3)mmHg比(29.7±11.0)mmHg(1 mmHg=0.133 kPa)]、供体心脏冷缺血时间[(274.7±105.6)min比(296.0±120.4)min]比较,差异均有统计学意义(P值均<0.05)。老龄组和非老龄组院内病死率[4.5%(7/157)比4.7%(42/887)]和1年病死率[5.7%(9/157)比6.5%(58/887)]比较,差异无统计学意义(P=0.88和0.70);老龄组中≥65岁受者的院内和术后1年病死率分别为10.0%(5/50)和14.0%(7/50),高于老龄组中<65岁受者的1.9%(2/107)和1.9%(2/107),且差异均有统计学意义(P=0.02和P<0.01)。Kaplan-Meier生存分析显示,老龄组远期存活率低于非老龄组,且差异有统计学意义(P=0.046);老龄组中≥65岁受者远期存活率低于非老龄组和老龄组中<65岁受者,且差异有统计学意义(P<0.01)。回归分析结果显示,受者年龄≥65岁、术前肌酐≥133μmol/L、总胆红素≥25.65μmol/L、术前ECMO辅助支持是心脏移植短期和长期死亡的独立危险因素。结论虽然老龄受者的长期预后略差于非老龄受者,但合并症少、术前状态较好的老龄受者院内病死率和术后1年病死率与非老龄受者相近,不应仅根据年龄将老龄受者常规排除在移植之外。年龄≥65岁受者的移植中远期预后不佳,在进行移植决策时需慎重。

Objective To explore the trends and outcomes for heart transplantation(HT)in elderly recipients and further examine the related risk factors.Methods Between June 2004 and December 2021,retrospective review was conducted for the relevant clinical data and age distribution of 1044 HT recipients aged≥18 year at Fuwai Hospital.The study population was assigned into two groups of elder(≥60 year,n=877)and non-elder(<60 year,n=157).Subgroup analysis was made between recipients aged<65 year(n=107)and those aged≥65 year(n=50)in elder group.Baseline demographic profiles,clinical data,in-hospital and one-year post-transplant mortality and long-term survival were compared between two groups.Then a further comparison of long-term survival was conducted among the groups of non-elder,elder aged<65 year and elder aged≥65 year.Cox proportional risk regression and multivariate Logistic regression models were utilized for examining the relevant risk factors for cumulative survival rate and short-term mortality.Kaplan-Meier analysis was employed for plotting survival curves and Log-rank test for comparison.Multivariate Cox proportional risk regression model was utilized for examining the relevant risk factors for cumulative survival rate and multivariate Logistic regression model for analyzing the relevant risk factors for short-term mortality.After adjusting for other confounding factors,the impact of recipient age on survival post-HT was determined.Results The number of elderly HT recipients spiked annually at our center while average age of adult recipients and average age of elderly recipients have remained relatively constant.The median follow-up period was 6.5 years.Regarding baseline data,statistically significant differences existed in ratio of males[84.7%(113/157)vs 77.5%(687/877)],hypertension history[20.4%(32/157)vs 8.9%(79/877)],smoking history[47.1%(74/157)vs 36.1%(320/877)],diabetic history[33.8%(53/157)vs 14.7%(130/877)],preoperative ICD/CRT/CRT-D implantation[28.0%(44/157)vs 18.0%(160/877)],value of creatinine[(105.3±25.3)vs(96.8±35.0)μmol/L],IMPACT score[(6.9±2.4)vs(4.2±2.9)point],serum total bilirubin[19.7(13.6,30.3)vs 23.7(15.8,36.8)μmol/L],mean pulmonary arterial pressure[(26.0±10.3)vs(29.7±11.0)mmHg(1 mmHg=0.133 kPa)]and ischemic duration[(274.7±105.6)vs(296.0±120.4)min](all P<0.05).No significant inter-group difference existed in in-hospital mortality[4.5%(7/157)vs 4.7%(42/887)]or 1-year mortality[5.7%(9/157)vs 6.5%(58/887)](P=0.88,P=0.70);in-hospital mortality and 1-year postoperative mortality of recipients aged≥65 years 10.0%(5/50)and 14.0%(7/50)were both higher than those aged<65 year[1.9%(2/107),1.9%(2/107)].The differences were both statistically significant(P=0.02,P<0.01).Kaplan-Meier survival analysis indicated that long-term survival rate was lower in elder group than that in non-elder group and the difference was statistically significant(P=0.046).Long-term survival rate of elders aged≥65 year was lower than that of non-elders aged<65 year and the difference was statistically significant(P<0.01).Regression analysis indicated that age of recipient≥65 year,preoperative creatinine≥133μmol/L,preoperative total bilirubin≥25.65μmol/L and preoperative support of extracorporeal membrane oxygenation(ECMO)were independent risk factors for short/long-term mortality post-HT.Conclusion Although long-term prognosis of elderly recipients is slightly worse than that of non-elderly ones,in-hospital mortality and one-year postoperative mortality are similar between two groups.For elderly recipients with fewer comorbidities and better preoperative status,they should not be excluded from HT based solely upon age.The long-term prognosis of recipients aged≥65 year remains poor and HT decisions should be made carefully.