Erickson K W, Costanzo-Nordin M R, O'Sullivan E J, Johnson M R, Zucker M J, Pifarré R, Lawless C E, Robinson J A, Scanlon P J
Section of Cardiology, Hines Veterans Administration Medical Center, Ill.
J Heart Transplant. 1990 Sep-Oct;9(5):526-37.
We reviewed the transpulmonary gradient, pulmonary arterial systolic pressure, pulmonary vascular resistance (Wood units), and pulmonary vascular resistance index (Wood units X Body surface area), recorded preoperatively in 109 recipients aged 44.6 +/- 13.5 (mean +/- SD) years who underwent orthotopic heart transplantation between March 1984 and March 1988, to identify which measure of pulmonary hypertension most accurately predicts poor outcome after orthotopic heart transplantation. These recipients were followed up as many as 57 (24.7 +/- 14.5) months after their transplant procedure. Preoperative hemodynamic values were as follows: transpulmonary gradient, 10.4 +/- 4.7 mm Hg; pulmonary artery systolic pressure, 53.6 +/- 14.8 mm Hg; pulmonary vascular resistance, 2.7 +/- 1.8 Wood units; pulmonary vascular resistance index, 4.9 +/- 2.7. Nineteen recipients died within 1 year after orthotopic heart transplantation. Causes of death were acute rejection (8), chronic rejection (1), infection (2), nonspecific orthotopic heart transplant failure (4), bowel ischemia (1), pancreatitis (1), lymphoma (1), and liver failure (1). Preoperative pulmonary arterial systolic pressure, pulmonary vascular resistance, and pulmonary vascular resistance index were not predictive of 1-month, 6-month, or 1-year mortality. One-month mortality rates of orthotopic heart transplant recipients with transpulmonary gradient greater than or equal to 12 mm Hg and of those with transpulmonary gradient less than 12 mm Hg were not significantly different (11% vs 3%; p = 0.12). The 6-month mortality rate of orthotopic heart transplant recipients with transpulmonary gradient greater than or equal to 12 mm Hg, however, was five times greater than that of orthotopic heart transplant recipients with transpulmonary gradient less than 12 mm Hg (24% vs 5%; p = 0.003), and 12-month mortality of orthotopic heart transplant recipients with transpulmonary gradient greater than or equal to 12 mm Hg was increased sevenfold when compared with that of orthotopic heart transplant recipients with transpulmonary gradient less than 12 mm Hg (36% vs 5%; p = 0.0005). These results suggest that presently used measures of pulmonary hypertension do not predict mortality in the first month after orthotopic heart transplantation, but that elevated preoperative transpulmonary gradient is associated with a significant increase in mortality at 6 and 12 months after orthotopic heart transplantation. Prospective randomized trials are needed to determined whether extended preload and afterload reduction before and/or after transplant will favorably influence long-term prognosis of orthotopic heart transplant recipients with elevated preoperative transpulmonary gradient.
我们回顾了1984年3月至1988年3月期间接受原位心脏移植的109例年龄为44.6±13.5（均值±标准差）岁受者术前记录的跨肺压差、肺动脉收缩压、肺血管阻力（伍德单位）和肺血管阻力指数（伍德单位×体表面积），以确定哪种肺动脉高压测量指标能最准确地预测原位心脏移植后的不良预后。这些受者在移植手术后随访了长达57（24.7±14.5）个月。术前血流动力学值如下：跨肺压差，10.4±4.7 mmHg；肺动脉收缩压，53.6±14.8 mmHg；肺血管阻力，2.7±1.8伍德单位；肺血管阻力指数，4.9±2.7。19例受者在原位心脏移植后1年内死亡。死亡原因包括急性排斥反应（8例）、慢性排斥反应（1例）、感染（2例）、非特异性原位心脏移植失败（4例）、肠缺血（1例）、胰腺炎（1例）、淋巴瘤（1例）和肝功能衰竭（1例）。术前肺动脉收缩压、肺血管阻力和肺血管阻力指数不能预测1个月、6个月或1年死亡率。跨肺压差大于或等于12 mmHg的原位心脏移植受者与跨肺压差小于12 mmHg的受者1个月死亡率无显著差异（11%对3%；p = 0.12）。然而，跨肺压差大于或等于12 mmHg的原位心脏移植受者6个月死亡率是跨肺压差小于12 mmHg的受者的5倍（24%对5%；p = 0.003），与跨肺压差小于12 mmHg的原位心脏移植受者相比，跨肺压差大于或等于12 mmHg的原位心脏移植受者12个月死亡率增加了7倍（36%对5%；p = 0.0005）。这些结果表明，目前使用的肺动脉高压测量指标不能预测原位心脏移植后第一个月的死亡率，但术前跨肺压差升高与原位心脏移植后6个月和12个月死亡率显著增加相关。需要进行前瞻性随机试验来确定移植前和/或移植后延长的前负荷和后负荷降低是否会对术前跨肺压差升高的原位心脏移植受者的长期预后产生有利影响。
