摘要
目的比较体外膜氧合(extracorporeal membrane oxygenation,ECMO)不同转流方式在特发性肺纤维化(idiopathic pulmonary fibrosis,IPF)合并肺动脉高压(pulmonary hypertension,PH)受者肺移植(lung transnsplantation,LTx)术中的应用效果。方法回顾性分析2017年1月至2020年12月于南京医科大学附属无锡人民医院经静脉-静脉ECMO(VV-ECMO组,68例)或静脉-动脉ECMO(VA-ECMO组,44例)辅助下行LTx手术的112例IPF合并PH受者的临床资料。对两组供者性别、年龄、机械通气时间、氧合指数和冷缺血时间;受者性别、年龄、吸烟史、术前PO_(2)、PCO_(2)、PH程度、NYHA心功能分级、右心功能、射血分数(ejection fraction,EF)和合并症(高血压和糖尿病),术中手术类型、手术时间、ECMO转流时间、失血量、输血量、尿量及术后输血量、机械通气时间、ICU滞留时间、再次开胸手术、肺部感染、原发性移植物功能不全(primary graft dysfunction,PGD)、肾功能不全等行单因素分析。再将单因素分析结果进一步纳入多因素分析,比较两种不同转流方式对LTx术后早期并发症和短期结局的影响。使用Cox比例风险模型比较VV-ECMO和VA-ECMO转流方式与移植术后受者生存相关的因素。结果VV-ECMO转流组术前PO_(2)为58.3(51.3,72.0)mmHg显著低于VA-ECMO组73.2(63.3,96.8)mmHg,组间比较,差异有统计学意义(P<0.006)。VA-ECMO组NYHAⅢ级、重度PH及术前右心增大者分别有24例(54.5%)、15例(34.1%)和22例(50.0%),与VV-ECMO组17例(25.0%)、6例(8.8%)和16例(23.5%)比较,差异均有统计学意义(P均<0.05)。两组移植术后PGD、术后机械通气时间(≥3 d)、肺部感染、术后再开胸比例、术后肾功能不全、ICU滞留时间、住院时间等方面比较,差异均无统计学意义(P均>0.05)。VV-ECMO组和VA-ECMO组受者术后6个月生存率分别为80.9%和61.4%,经多因素Cox回归模型校正后,两组之间短期存活率(6个月)差异无统计学意义(P>0.05)。多因素统计结果显示,VV-ECMO组术后延迟撤机的风险是VA-ECMO组的14.452倍,组间比较,差异有统计学意义(95%CI:2.448~85.323,P=0.03)。结论合并轻度PH的IPF受者采用VV-ECMO模式与合并重度PH的IPF受者采用VA-ECMO转流方式相比,术后并发症发生率和短期存活率差异均无统计学意义。VV-ECMO转流可延迟移植术后撤机时间。
Objective To compare the effect of extracorporeal membrane oxygenation(ECMO)on pulmonary transplantation(LTx)in patients with idiopathic pulmonary fibrosis(IPF)complicated with pulmonary hypertension(PH).Methods From January 2017 to December 2020,clinical data were retrospectively reviewed for 112 IPF patients complicated with PH undergoing LTx assisted by venous ECMO(VV-ECMO group,n=68)or venous arterial ECMO(VA-ECMO group,n=44).Gender,age,mechanical ventilation time,oxygenation index,cold ischemic time,preoperative gender,age,smoking history,PO_(2),PCO_(2),PH degree,NYHA cardiac function grade,right cardiac function,ejection fraction(EF)and complications(hypertension&diabetes)of two groups were compared.Intraoperative approach,operative duration,ECMO transfer time,blood loss,blood transfusion,urine volume,postoperative blood transfusion,mechanical ventilation time,ICU stay time,re-thoracotomy,pulmonary infection,primary graft dysfunction(PGD)and renal insufficiency were recorded.And the effects of two different diversion modes on early postoperative complications and short-term outcomes of LTx were further analyzed by multiple factors.Cox proportional risk model was employed for comparing VV-ECMO and VA-ECMO flow patterns with factors related to recipient survival after transplantation.Results The preoperative PO_(2)of 58.3(51.3,72.0)mmHg was significantly lower in VV-ECMO bypass group than that of 73.2(63.3,96.8)mmHg in VA-ECMO group and the difference was statistically significant(P<0.006).Compared with VV-ECMO group,24(54.5%),15(34.1%)and 22(50.0%)had NYHA classⅢ,severe PH and preoperative right heart enlargement in VA-ECMO group respectively and the differences were statistically significant compared with 17(25.0%),6(8.8%)and 16(23.5%)in VV-ECMO group(P<0.05 for all).No significant inter-group differences existed in postoperative PGD,postoperative mechanical ventilation time(≥3 d),pulmonary infection,postoperative thoracotomy ratio,postoperative renal insufficiency,ICU stay,hospital stay and other aspects(P>0.05).And 6-month postoperative survival rates of VV-ECMO and VA-ECMO groups were 80.9%and 61.4%,respectively and no significant inter-group difference existed in short-term survival rate(6 months)after adjustment by multivariate Cox regression model(P>0.05).Multivariate statistics indicated that the risk of delayed postoperative withdrawal was 14.452-fold higher in VV-ECMO group than in VA-ECMO group and the inter-group difference was statistically significant(95%CI:2.448-85.323,P=0.03).Conclusions No differences exist in postoperative complications or short-term survival rate between IPF recipients with mild PH on VV-ECMO mode and IPF recipients with severe PH on VA-ECMO mode.VV-ECMO flow reversal can delay the transplant back-off time.
作者
于慧智
胡春兰
王净
顾思佳
宋志云
戴韬寅
李小杉
陈静瑜
胡春晓
Yu Huizhi;Hu Chunlan;Wang Jing;Gu Sijia;Song Zhiyun;Dai Taoyin;Li Xiaoshan;Chen Jingyu;Hu Chunxiao(Department of Anesthesiology,the Affiliated Wuxi People's Hospital of Nanjing Medical University,Wuxi 214023,China;Department of Lung Transplantation Center,The Affiliated Wuxi People's Hospital of Nanjing Medical University,Wuxi 214023,China;Department of Transplant Anesthesiology,The Affiliated Wuxi People's Hospital of Nanjing Medical University,Wuxi 214023,China)
出处
《中华器官移植杂志》
CAS
2022年第5期281-286,共6页
Chinese Journal of Organ Transplantation
基金
国家自然科学基金(8207011015)
无锡市科技发展计划项目(N20202029)
无锡市卫生健康委员会青年科研项目(Q202003)。
关键词
肺纤维化
肺动脉高压
肺移植
体外膜氧合
Pulmonary fibrosis
Pulmonary hypertension
Lung transplantation
Extracorporeal membrane oxygenerator
