1、终末期心力衰竭的生存评估和心脏移植治疗,心力衰竭的非药物治疗,起搏器治疗机械辅助治疗心脏移植,UCHSC HTX（C、D期HF）,BEST/布新洛尔(C期HF）COPERNICUS/卡维地洛（ C期HF ）COMPANION/CRT-D）（C期HF ）RALES/螺内酯(C期HF）,Consensus/依那普利（1985-86）（C/D期HF）U.Minnesota(1979-84) (C/D期HF ）Consensus/安慰剂(1985-86)(C/D期HF),C期、D期HF心脏移植后的成活率优于药物疗法或药物器械疗法,心脏移植与药物和器械治疗C/D期心衰比较,Braunwalds Hear
2、t Disease 5th edition,NUMBER OF HEART TRANSPLANTS REPORTED BY YEAR,ISHLT,NOTE: This figure includes only the heart transplants that are reported to the ISHLT Transplant Registry. As such, the presented data may not mirror the changes in the number of heart transplants performed worldwide,2009,心脏移植例数
3、/年,2004.6 2010.5 总数 197例,HTx受体病因诊断,ISHLT,2009,HTx受体术前血流动力学评价,HTx受体术前器械治疗,HEART TRANSPLANTATION Kaplan-Meier Survival (1/1982-6/2005),ISHLT,N at risk at 22 years: 145,HEART TRANSPLANTATION Kaplan-Meier Survival (1/1982-6/2007),2009,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by Diagnosis (Trans
4、plants: 1/1982-6/2007),ISHLT,2009,心脏移植受体的年龄,ISHLT,2009,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by Age Group (Transplants: 1/2002-6/2007),ISHLT,2009,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by PVR (Transplants: 1/2002-6/2007),ISHLT,2009,PVR: 5+ Wood units,ADULT HEART TRANSPLANTATIO
5、N Kaplan-Meier Survival by VAD usage (Transplants: 4/1994-6/2007),ISHLT,2009,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by Era (Transplants: 1/1982 6/2007),ISHLT,2009,Half-life = 10.0 yearsConditional Half-life = 13.0 years,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival by Era (Transplants
6、: 1/1982 6/2007) Diagnosis: Retransplant,ISHLT,2009,ADULT HEART RECIPIENTS Functional Status of Surviving Recipients (Follow-ups: 1995 - June 2008),ISHLT,2009,ADULT HEART RECIPIENTS Maintenance Immunosuppression at Time of Follow-up(Follow-ups: January 2005 - June 2008),NOTE: Different patients are
7、analyzed in Year 1 and Year 5,ISHLT,Analysis is limited to patients who were alive at the time of the follow-up,2009,HTx术后1年内 EXPERIENCING REJECTION IN 1ST YEAR,Overall,18-44,45-62,63+,Female,Male,ISHLT analysis is limited to patients who were alive at the time of the follow-up, (Follow-ups: July 1,
8、 2004 - June 30, 2007),J Heart Lung Transplant 2008;27: 937-983,阜外160例心脏移植病人的506 例次心内膜心肌活检结果,ADULT HEART TRANSPLANTATION Kaplan-Meier Survival Stratified by Treatment for Rejection Within 1st YearConditional on survival to 1 year (follow-ups: 7/2004-6/2007),ISHLT,Treated rejection = Recipient was re
9、ported to (1) have at least one acute rejection episode that was treated with an anti-rejection agent; or (2) have been hospitalized for rejection.No rejection = Recipient had (i) no acute rejection episodes and (ii) was reported either as not hospitalized for rejection or did not receive anti-rejec
10、tion agents.,2009,POST-HEART TRANSPLANT MORBIDITY FOR ADULTS Cumulative Prevalence in Survivors within 1 and 5 Years Post-Transplant (Transplants: 2000 - June 2003)For the Same Patients,ISHLT,2009,FREEDOM FROM SEVERE RENAL DYSFUNCTION BY ERA* For Adult Heart Recipients (Transplants: April 1994-June
11、2007),ISHLT,2009,ADULT HEART TRANSPLANT RECIPIENTS: Relative Incidence of Leading Causes of Death (Deaths: January 1992 - June 2008),ISHLT,2009,ADULT HEART TRANSPLANTS (1/2002-6/2007) Risk Factors for 1 Year Mortality,(N=10,705),* Temporary circulatory support includes ECMO and Abiomed.NOTE: There w
12、ere too few continuous flow devices to analyze.,ADULT HEART TRANSPLANTS (1/2002-6/2007) Risk Factors for 1 Year Mortality,ADULT HEART TRANSPLANTS (1/2002-6/2007) Relative Risk of 1 Year Mortality with 95% Confidence Limits,ADULT HEART TRANSPLANTS (1/2002-6/2007) Factors Not Significant for 1 Year Mo
13、rtality,Recipient Factors: Prior malignancy, hospitalized, prior pregnancy, balloon pump, diabetes, PRADonor Factors: Clinical infection, history of diabetes, gender, history of hypertension, cause of death, history of malignancyTransplant Factors: HLA mismatch, CMV mismatch, prior transplant,ADULT
14、HEART TRANSPLANTS (1/2000-6/2003) Risk Factors for 5 Year Mortality,(N=7,171),* Temporary circulatory support includes ECMO and Abiomed,NOTE: There were too few continuous flow devices to analyze.,ADULT HEART TRANSPLANTS (1/2000-6/2003) Risk Factors for 5 Year Mortality,(N=7,171),ADULT HEART TRANSPL
15、ANTS (1/2000-6/2003) Factors Not Significant for 5 Year Mortality,Recipient Factors: Sternotomy, pulmonary embolism, IV inotropes, transfusions, prior malignancy, PRA, balloon pump, infection requiring IV antibiotics prior to transplantDonor Factors: History of cancer, clinical infection, cause of d
16、eath, history of hypertension, height, weightTransplant Factors: CMV mismatch, ABO match,ADULT HEART TRANSPLANTS (7/1994-6/1998) Risk Factors for 10 Year Mortality,(N=8,818),ADULT HEART TRANSPLANTS (7/1994-6/1998) Risk Factors for 10 Year Mortality,(N=8,818),ADULT HEART TRANSPLANTS (1989-6/1993) Ris
17、k Factors for 15 Year MortalityConditional on Survival to 5 Years,(N=4,816),ADULT HEART TRANSPLANTSRisk Factors for 15 Year Mortality Conditional on Survival to 5 Years,(N=4,816),ADULT HEART TRANSPLANTS (1982-6/1987) Risk Factors for 20 Year Mortality,(N=4,487),ADULT HEART TRANSPLANTSRisk Factors fo
18、r 20 Year Mortality,(N=4,487),心脏移植的禁忌证,不可逆的肺动脉高压不可逆的其他脏器（肝/肾/肺）功能不全，除非接受联合器官移植严重的外周血管病变和脑血管疾病恶性肿瘤病史，且可能复发已有糖尿病并发症（视网膜病变、肾病）不能遵循复杂的治疗流程全身性的感染活动期,心脏移植手术危险因素评估,* 平均PAP与PCWP之差,心脏移植适应证选择,积极的药物治疗不能控制或仍反复发作的心力衰竭,估计1年生存的可能性40%),临床因素收缩/舒张性HF合并肾功能不全病人心血管死亡/ HF加重住院,J Am Coll Cardiol 2008;52:99-1003,Circulation
19、 2003;107:1991-1997,临床因素不同尿酸水平的慢性心力衰竭病人（n=182) Kaplan-Meier生存曲线,临床因素阻塞性睡眠呼吸障碍对HF病人死亡率的影响,Wang H ， J. Am. Coll. Cardiol. 2007;49:1625-1631,结构性因素与心力衰竭存活,左室容积、心室质量和球形指数二尖瓣、三尖瓣返流程度与K-M存活曲线 MR 分级： 无-轻度 1004 +/-31 天 中度 795 +/-34 天 重度 628 +/-47 天 TR分级： 无-轻度 977 +/-28 天 中度 737 +/-40 天 重度 658 +/-55 天左房扩大,Am
20、J Cardiol. 2000;85:624-629.,血流动力学指标,研究显示右房压、肺动脉压、PCWP、CO等与死亡率相关，但是这些静息血流动力学指标的预后价值普遍不高另外一些研究观察了急性血流动力学变化与长期预后的关系；然而临床对照研究显示，改善血流动力学的治疗并不一定改善远期预后,Predictors of short-term outcome in Chinese patients with ambulatory heart failure for heart transplantation with ejection fraction 25%,Jpn Heart J. 2000;4
21、1(3):349-69,Predictors of short-term outcome in Chinese patients with ambulatory heart failure for heart transplantation with ejection fraction 25%,Jpn Heart J. 2000;41(3):349-69,Predictors of short-term outcome in Chinese patients with ambulatory heart failure for heart transplantation with ejectio
22、n fraction 25%,Jpn Heart J. 2000;41(3):349-69,LVEF,. Circulation 1993,87:V15-16,运动耐量Vo2max和SBP预测慢性心力衰竭生存,BNP/炎症因子/坏死标记物/TnI和TnT预测HF死亡,BNP 和NT-proBNP 是预测严重HF死亡金指标肿瘤坏死因子：心衰患者血清中TNF及其可溶性受体水平增加，与死亡率相关。CRP：高水平CRP是致病和死亡独立预测因子。TnI和TnT：HF不良预后的独立预测因子，并且独立于缺血性病因。高尿酸：独立于肾功能和利尿剂剂量是氧化代谢受损和胰岛素敏感性下降、炎性因子激活和血管功能受损的
23、标志。中-重度慢性HF预测死亡较强的预测因子。,HF经最佳药物治疗后BNP 和 IL-6仍是存活的独立预测因子(n=102),JAMA.2005;293:1609-1616,BNP/CRP联合预测死亡/HF-住院/心脏移植的危险(n=118),J heart lung transpl 2007；28：622-629,TnT及动态变化对原发性扩张型心肌病预后的影响(n=60),TnT 0.02 ng/mLn=33,TnT decreasing n=10,TnT persistently increased n=17,Circulation. 2001;103:369,Circulation 20
24、07;116:1242-1249,K-M cumulative curves for mortality by cTnT (A) / by quartiles of hsTnT (B) / cTnI levels,Circulation 2003;108:833-838,总结 心衰存活的独立预测因子,年龄/性别/HF病因/恶液质/血压活动耐量 (NYHA class, 6-MWD, peak VO2)射血分数 (EF)心肾综合症 (肾功能, Hb,) RAAS活性 (利尿剂剂量, 血钠)细胞因子激活 (Hb/ WBC/ %淋巴细胞计数) BNPTNI / TNT 药物治疗和机械辅助,Levy, W. C. et al. Circulation 2006;113:1424-1433,Thank you !,
