John R, Rajasinghe H, Chen J M, Weinberg A D, Sinha P, Itescu S, Lietz K, Mancini D, Oz M C, Smith C R, Rose E A, Edwards N M
Departments of Surgery and Cardiology, Columbia University College of Physicians and Surgeons, New York City, New York, USA.
Ann Surg. 2000 Sep;232(3):302-11. doi: 10.1097/00000658-200009000-00002.
To study risk factors for early and late death after heart transplantation in the current era.
The current cardiac transplant population differs from earlier periods in that an increasing number of sicker patients, such as those with ventricular assist device (LVAD) support, prior cardiac allotransplantation, and pulmonary hypertension, are undergoing transplantation. In addition, sensitized patients constitute a greater proportion of the transplanted population. Emphasis has been placed on therapies to prevent early graft loss, such as the use of nitric oxide and improved immunosuppression, in addition to newer therapies.
Five hundred thirty-six patients undergoing heart transplantation between 1993 and 1999 at a single center were evaluated (464 adults and 72 children; 109 had received prior LVAD support and 24 underwent retransplantation). The mean patient age at transplantation was 44.9 years. Logistic regression and Cox proportional hazard models were used to evaluate the following risk factors on survival: donor and recipient demographics, ischemic time, LVAD, retransplantation, pretransplant pulmonary vascular resistance, and immunologic variables (ABO, HLA matching, and pretransplant anti-HLA antibodies).
The rate of early death (less than 30 days) was 8.5% in adults and 8.8% in children. The actuarial survival rate of the 536 patients was 83%, 77%, and 71% at 1, 3, and 5 years, respectively, by Kaplan Meier analysis. Risk factors adversely affecting survival included the year of transplant, donor age, and donor-recipient gender mismatching. Neither early nor late death was influenced by elevated pulmonary vascular resistance, sensitization, prior LVAD support, or prior cardiac allotransplantation.
Previously identified risk factors did not adversely affect short- or long-term survival of heart transplant recipients in the current era. The steady improvement in survival during this period argues that advances in transplantation have offset the increasing acuity of transplant recipients.
研究当代心脏移植术后早期和晚期死亡的危险因素。
当前心脏移植人群与早期不同，越来越多病情较重的患者，如接受心室辅助装置（LVAD）支持、曾接受心脏同种异体移植以及患有肺动脉高压的患者正在接受移植。此外，致敏患者在移植人群中所占比例更大。除了新的治疗方法外，人们还将重点放在预防早期移植物丢失的治疗上，如使用一氧化氮和改进免疫抑制。
对1993年至1999年在单一中心接受心脏移植的536例患者进行评估（464例成人和72例儿童；109例曾接受LVAD支持，24例接受再次移植）。移植时患者的平均年龄为44.9岁。采用逻辑回归和Cox比例风险模型评估以下生存危险因素：供体和受体人口统计学特征、缺血时间、LVAD、再次移植、移植前肺血管阻力以及免疫变量（ABO血型、HLA配型和移植前抗HLA抗体）。
成人早期死亡（少于30天）率为8.5%，儿童为8.8%。通过Kaplan Meier分析，536例患者的1年、3年和5年精算生存率分别为83%、77%和71%。对生存有不利影响的危险因素包括移植年份、供体年龄和供受体性别不匹配。早期和晚期死亡均不受肺血管阻力升高、致敏、既往LVAD支持或既往心脏同种异体移植的影响。
先前确定的危险因素在当代并未对心脏移植受者的短期或长期生存产生不利影响。在此期间生存率的稳步提高表明移植技术的进步抵消了移植受者病情日益加重的影响。
