Gajarski R J, Towbin J A, Bricker J T, Radovancevic B, Frazier O H, Price J K, Schowengerdt K O, Denfield S W
Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston 77030.
J Am Coll Cardiol. 1994 Jun;23(7):1682-7. doi: 10.1016/0735-1097(94)90675-0.
This study examined perioperative and intermediate outcomes in pediatric cardiac transplant recipients who had elevated pulmonary vascular resistance indexes preoperatively.
Elevated pulmonary vascular resistance was associated with poor outcome in previous studies and constitutes a relative contraindication to transplantation. Few studies have evaluated this poor outcome risk factor in pediatric patients.
To evaluate outcomes of nonneonatal transplant recipients, records were reviewed and divided into Group I (preoperative pulmonary vascular resistance index > or = 6 units.m2) and Group II (pulmonary vascular resistance index < 6 units.m2). Donor/recipient weight ratios, ischemic times, length of intensive care unit stay, posttransplantation infection rates, arrhythmia, response to pretransplantation vasodilator infusions and pulmonary vascular resistance indexes at the first and most recent posttransplantation biopsies were analyzed.
Group I (8 patients) had a mean (+/- SEM) pulmonary vascular resistance index of 11.5 +/- 3.5 units,m2; Group II (29 patients) had a mean pulmonary vascular resistance index of 2.3 +/- 0.4 units,m2 (p < 0.002). Pulmonary vascular resistance index decreased from 12.3 +/- 3.9 to 3.9 +/- 0.9 units.m2 (p < 0.05) in 7 Group I patients undergoing vasodilator infusion during pretransplantation catheterization. Thirty-six orthotopic heart transplantations were performed and one heterotopic transplantation. Donor weights exceeded recipient weights by 13% and 31% for Groups I and II, respectively (p > 0.25). Donor ischemic time was 215 min for Group I and 225 min for Group II (p > 0.75). Intensive care unit stay was 11.5 days in Group I and 15.1 days in Group II (p = 0.20). Infection rate was 38% in both groups (p > 0.80). Arrhythmias occurred in 90% of Group I and 42% in Group II (p < 0.03) patients. Pulmonary resistance index in Group I decreased from 11.5 +/- 3.5 to 3.3 +/- 1.2 units.m2 (p < 0.03) by the first posttransplantation biopsy and have not changed subsequently. During 2.3 years (range 0.3 to 8.5) of follow-up, the mortality rate was 25% and 21% for Groups I and II, respectively (p > 0.80).
Group I patients did not require significantly oversized donors, restricted donor locations or longer intensive care unit stays or have higher infection rates; however, arrhythmias were more frequent. Pulmonary resistance index normalized early after transplantation. Pulmonary vascular reactivity may be more important for survival than absolute resistance index.
本研究调查了术前肺血管阻力指数升高的小儿心脏移植受者的围手术期及中期结局。
在以往研究中，肺血管阻力升高与不良结局相关，是移植的相对禁忌证。很少有研究评估小儿患者中这种不良结局危险因素。
为评估非新生儿移植受者的结局，回顾病历并分为I组（术前肺血管阻力指数≥6单位·m²）和II组（肺血管阻力指数<6单位·m²）。分析供体/受体体重比、缺血时间、重症监护病房住院时间、移植后感染率、心律失常、移植前血管扩张剂输注反应以及首次和最近一次移植后活检时的肺血管阻力指数。
I组（8例患者）平均（±标准误）肺血管阻力指数为11.5±3.5单位·m²；II组（29例患者）平均肺血管阻力指数为2.3±0.4单位·m²（p<0.002）。7例在移植前导管插入术期间接受血管扩张剂输注的I组患者，其肺血管阻力指数从12.3±3.9降至3.9±0.9单位·m²（p<0.05）。共进行了36例原位心脏移植和1例异位移植。I组和II组供体体重分别超过受体体重13%和31%（p>0.25）。I组供体缺血时间为215分钟，II组为225分钟（p>0.75）。I组重症监护病房住院时间为11.5天，II组为15.1天（p = 0.20）。两组感染率均为38%（p>0.80）。I组90%的患者和II组42%的患者发生心律失常（p<0.03）。I组移植后首次活检时肺阻力指数从11.5±3.5降至3.3±1.2单位·m²（p<0.03），随后未再变化。在2.3年（范围0.3至8.5年）的随访中，I组和II组的死亡率分别为25%和21%（p>0.80）。
I组患者不需要明显过大的供体、受限的供体位置或更长的重症监护病房住院时间，感染率也不高；然而，心律失常更频繁。移植后早期肺阻力指数恢复正常。肺血管反应性对生存可能比绝对阻力指数更重要。
