基于术前肺动脉压评估心脏移植术后右心衰竭的发生风险

doi:10.11958/20250560

摘要/Abstract

摘要：

目的基于术前肺动脉压建立列线图评估心脏移植术后右心衰竭发生风险并进行验证。方法回顾性纳入接受心脏移植术患者184例，将患者分为训练集（126例）和验证集（58例）。依据术后是否发生右心衰竭将训练集患者分为右心衰组（60例）和非右心衰组（66例），比较2组患者临床资料的差异，对训练集患者运用Lasso-Logistic回归筛选术后发生右心衰竭的影响因素。根据筛选的影响因素绘制列线图，并利用受试者工作特征（ROC）曲线、校准曲线及临床决策曲线评估模型的预测效能。进一步在验证集中评价模型的临床应用效果。结果 Lasso-Logistic回归共筛选出总胆红素升高（OR=2.649，95%CI：1.339~5.239）、平均肺动脉压增大（OR=3.082，95%CI：1.608~5.910）、肺动脉阻力增大（OR=3.171，95%CI：1.710~5.879）、右心室流出道内径增宽（OR=2.681，95%CI：1.361~5.281）是心脏移植患者术后发生右心衰竭的危险因素；依此构建列线图模型，模型的曲线下面积（AUC）为0.846（95%CI：0.813~0.947），校准曲线显示模型拟合良好（Hosmer-Lemeshoe χ²=0.862，P=0.361）。临床决策曲线结果显示，高风险阈值概率在1%~95%时净获益率>0，该列线图模型能产生较好的临床效益。根据列线图模型预测结果，验证集58例患者中34例被预测为右心衰竭高风险，24例为低风险，实际诊断结果显示29例发生右心衰竭，29例未发生，Kappa系数为0.483（95%CI：0.261~0.705）。结论术前肺动脉收缩压增大是心脏移植患者术后发生右心衰竭的独立危险因素，通过联合其他临床危险因素构建患者术后发生右心衰竭的列线图预测模型具有良好的预测效能。

关键词: 心脏移植, 心力衰竭, 肺动脉压, 预测模型, 列线图

Abstract:

Objective To evaluate the risk of right heart failure after heart transplantation by establishing nomogram based on preoperative pulmonary artery pressure. Methods A total of 184 patients undergoing heart transplantation were retrospectively collected and divided into the training group (126 cases) and the verification group (58 cases). Patients in the training set were divided into the right heart failure group (60 cases) and the non-right heart failure group (66 cases) according to whether right heart failure occurred after operation. The differences of clinical data between the two groups were compared, and the influencing factors of right heart failure occurred after operation in the training set were screened by Lasso-Logistic regression. According to the screened influencing factors, nomograms were drawn, and the predictive efficiency of the model was evaluated by using the receiver's operating characteristic (ROC) curve, calibration curve, receiver's operating characteristic (ROC) curve and clinical decision curve. Further vertification of the clinical application effect of centralized evaluation model was conducted. Results The Lasso-Logistic regression analysis identified the following independent risk factors for right heart failure after heart transplantation: elevated total bilirubin (OR=2.649, 95%CI: 1.339-5.239), increased mean pulmonary artery pressure (OR=3.082, 95%CI: 1.608-5.910), elevated pulmonary artery resistance (OR=3.171, 95%CI: 1.710-5.879), and widened right ventricular outflow tract diameter (OR=2.681, 95%CI: 1.361-5.281), all of which demonstrated statistical significance (P<0.05). The nomogram model was constructed accordingly. The AUC of the nomogram model was 0.846 （95%CI: 0.813-0.947). The calibration curve demonstrated good fit via the goodness-of-fit test (Hosmer-Lemeshow χ²=0.862, P=0.361). Clinical decision curve analysis revealed that the net benefit rate remained >0 when the high-risk threshold probability ranged from 1% to 95%, indicating favorable clinical utility of this nomogram model. Based on the model predictions, among 58 heart transplant patients in the validation cohort, 34 were classified as high-risk for right heart failure and 24 as low-risk. Actual diagnosis results showed 29 cases with right heart failure and 29 without. The Kappa coefficient reached 0.483 (95%CI: 0.261-0.705), demonstrating high consistency between model predictions and actual clinical outcomes. Conclusion Preoperative pulmonary systolic pressure increase is an independent risk factor for right heart failure after heart transplantation. A nomogram prediction model for right heart failure after heart transplantation is established by combining other clinical risk factors, and it has good prediction efficiency.

Key words: heart transplantation, heart failure, pulmonary artery pressure, prediction model, nomogram

中图分类号:

R541.9

图/表 8

表1 训练集和验证集基本资料比较

Tab.1 Comparison of basic data between training set and verification set

组别	n	性别（男/女）	年龄/岁	BMI/（kg/m²）	NYHA心功能分级（Ⅲ级/Ⅳ级）	吸烟史
训练集	126	90/36	49.52±9.02	22.37±1.41	88/38	82（65.1）
验证集	58	44/14	48.64±8.75	22.15±1.36	40/18	32（55.2）
χ²或t		0.394	0.621	0.994	0.344	1.654

表2 右心衰组和非右心衰组临床特征比较

Tab.2 Comparison of clinical characteristics between the right heart failure group and the non-failure group

图1 Lasso回归筛选变量过程 A：自变量回归系数变化轨迹；B：交叉验证曲线。

Fig.1 Selection process for Lasso regression

表3 心脏移植患者术后发生右心衰竭的多因素Logistic回归分析

Tab.3 Multivariate Logistic regression analysis of right heart failure after heart transplantation

变量	β	SE	Wald χ²	P	OR	OR 95%CI
TBIL	0.974	0.348	7.834	0.005	2.649	1.339~5.239
mPAP	1.126	0.332	11.503	<0.001	3.082	1.608~5.910
PVR	1.154	0.315	13.421	<0.001	3.171	1.710~5.879
RVOTD	0.986	0.346	8.121	0.004	2.681	1.361~5.281
常数项	-3.210	0.850	14.256	<0.001	0.040

图2 心脏移植患者术后发生右心衰竭的风险预测列线图

Fig.2 Nomogram for risk prediction of right heart failure after heart transplantation

图3 列线图模型的校准曲线

Fig.3 Calibration curve of the nomogram model

图4 列线图模型预测右心衰竭的ROC曲线

Fig.4 ROC curve of the nomogram model for predicting right heart failure

图5 训练集列线图模型的临床决策曲线

Fig.5 The decision curve analysis of nomogram model

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