Del Rizzo D F, Menkis A H, Pflugfelder P W, Novick R J, McKenzie F N, Boyd W D, Kostuk W J
London Health Sciences Centre, University of Western Ontario, London, Canada.
J Heart Lung Transplant. 1999 Apr;18(4):310-9. doi: 10.1016/s1053-2498(98)00059-x.
The advances in immunotherapy, along with a liberalization of eligibility criteria have contributed significantly to the ever increasing demand for donor organs. In an attempt to expand the donor pool, transplant programs are now accepting older donors as well as donors from more remote areas. The purpose of this study is to determine the effect of donor age and organ ischemic time on survival following orthotopic heart transplantation (OHT).
From April 1981 to December 1996 372 adult patients underwent OHT at the University of Western Ontario. Cox proportional hazards models were used to identify predictors of outcome. Variables affecting survival were then entered into a stepwise logistic regression model to develop probability models for 30-day- and 1-year-mortality.
The mean age of the recipient population was 45.6 +/- 12.3 years (range 18-64 years: 54 < or = 30; 237 were 31-55; 91 > 56 years). The majority (329 patients, 86.1%) were male and the most common indications for OHT were ischemic (n = 180) and idiopathic (n = 171) cardiomyopathy. Total ischemic time (TIT) was 202.4 +/- 84.5 minutes (range 47-457 minutes). In 86 donors TIT was under 2 hours while it was between 2 and 4 hours in 168, and more than 4 hours in 128 donors. Actuarial survival was 80%, 73%, and 55% at 1, 5, and 10 years respectively. By Cox proportional hazards models, recipient status (Status I-II vs III-IV; risk ratio 1.75; p = 0.003) and donor age, examined as either a continuous or categorical variable ([age < 35 vs > or = 35; risk ratio 1.98; p < 0.001], [age < 50 vs > or = 50; risk ratio 2.20; p < 0.001], [age < 35 vs 35-49 versus > or = 50; risk ratio 1.83; p < 0.001]), were the only predictors of operative mortality. In this analysis, total graft ischemic time had no effect on survival. However, using the Kaplan-Meier method followed by Mantel-Cox logrank analysis, ischemic time did have a significant effect on survival if donor age was > 50 years (p = 0.009). By stepwise logistic regression analysis, a probability model for survival was then developed based on donor age, the interaction between donor age and ischemic time, and patient status.
Improvements in myocardial preservation and peri-operative management may allow for the safe utilization of donor organs with prolonged ischemic times. Older donors are associated with decreased peri-operative and long-term survival following. OHT, particularly if graft ischemic time exceeds 240 minutes and if these donor hearts are transplanted into urgent (Status III-IV) recipients.
免疫疗法的进展以及入选标准的放宽，极大地推动了对供体器官需求的不断增长。为了扩大供体库，移植项目现在开始接受年龄较大的供体以及来自更偏远地区的供体。本研究的目的是确定供体年龄和器官缺血时间对原位心脏移植（OHT）后存活情况的影响。
1981年4月至1996年12月，372例成年患者在西安大略大学接受了原位心脏移植。采用Cox比例风险模型来确定预后的预测因素。然后将影响存活的变量纳入逐步逻辑回归模型，以建立30天和1年死亡率的概率模型。
受体人群的平均年龄为45.6±12.3岁（范围18 - 64岁：54例≤30岁；237例为31 - 55岁；91例＞56岁）。大多数（329例患者，86.1%）为男性，原位心脏移植最常见的适应证是缺血性（n = 180）和特发性（n = 171）心肌病。总缺血时间（TIT）为202.4±84.5分钟（范围47 - 457分钟）。86例供体的总缺血时间在2小时以内，168例在2至4小时之间，128例供体的总缺血时间超过4小时。1年、5年和10年的精算生存率分别为80%、73%和55%。通过Cox比例风险模型，受体状态（I - II级与III - IV级；风险比1.75；p = 0.003）以及供体年龄，无论是作为连续变量还是分类变量进行检验（[年龄＜35岁与≥35岁；风险比1.98；p＜0.001]，[年龄＜50岁与≥50岁；风险比2.20；p＜0.001]，[年龄＜35岁与35 - 49岁以及≥50岁；风险比1.83；p＜0.001]），是手术死亡率的唯一预测因素。在此分析中，总移植物缺血时间对存活无影响。然而，采用Kaplan - Meier方法随后进行Mantel - Cox对数秩分析，如果供体年龄＞50岁，缺血时间对存活确实有显著影响（p = 0.009）。通过逐步逻辑回归分析，基于供体年龄、供体年龄与缺血时间的相互作用以及患者状态，建立了一个存活概率模型。
心肌保存和围手术期管理的改善可能允许安全使用缺血时间延长的供体器官。年龄较大的供体与原位心脏移植术后围手术期和长期存活率降低相关，特别是如果移植物缺血时间超过240分钟，并且如果将这些供体心脏移植给紧急（III - IV级）受体。
