John R, Rajasinghe H A, Chen J M, Weinberg A D, Sinha P, Mancini D M, Naka Y, Oz M C, Smith C R, Rose E A, Edwards N M
Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA.
Ann Thorac Surg. 2001 Aug;72(2):440-9. doi: 10.1016/s0003-4975(01)02784-9.
Constantly changing practices in heart transplantation have improved posttransplant survival in patients with end-stage heart disease. The objective of this study was to evaluate long-term outcomes in different eras of immunosuppressive therapy after cardiac transplantation at a single center during a two-decade period.
A retrospective review of 1,086 consecutive cardiac allograft recipients who underwent transplantation between 1977 to 1999 was performed. Patients were divided into four eras based on type of immunosuppressive therapy: era 1 = steroids, azathioprine (n = 26, February 1977 to March 1983), era II = steroids, cyclosporine (n = 43, April 1983 to April 1985), era III = cyclosporine, steroids, azathioprine (n = 752, April 1985 to December 1995), era IV = cyclosporine, steroids, mycophenolate mofetil (n = 315, January 1996 to October 1999).
The actuarial survival of the entire cohort of 1,086 patients undergoing cardiac transplantation was 79%, 66%, and 49% at 1, 5, and 10 years, respectively. There were significant trends in recipient age and gender distribution among the four eras with increasing proportion of older age (> 60 years) and female recipients in eras III and IV (p = 0.001 and 0.02). Early mortality and long-term survival improved significantly over all eras (p < 0.001). Rejection as a cause of death decreased over time (era I, 24%; era II, 21%; era III, 15%; era IV, 9%; p = 0.02), whereas the contribution of transplant coronary artery disease as a cause of death remained unchanged.
Cardiac transplantation provides satisfactory long-term survival for patients with end-stage heart failure. The improving outcomes in survival correlate with improved immunosuppressive therapy in each era. Although the reasons for improvement in survival over time are multifactorial, we believe that changes in immunosuppressive therapy have had a major impact on survival as evidenced by the decreasing number of deaths due to rejection.
心脏移植实践的不断变化提高了终末期心脏病患者移植后的生存率。本研究的目的是评估在一个单一中心20年期间心脏移植后不同免疫抑制治疗时代的长期结果。
对1977年至1999年间连续接受移植的1086例心脏移植受者进行回顾性研究。根据免疫抑制治疗类型将患者分为四个时代：时代1 = 类固醇、硫唑嘌呤（n = 26，1977年2月至1983年3月），时代II = 类固醇、环孢素（n = 43，1983年4月至1985年4月），时代III = 环孢素、类固醇、硫唑嘌呤（n = 752，1985年4月至1995年12月），时代IV = 环孢素、类固醇、霉酚酸酯（n = 315，1996年1月至1999年10月）。
1086例接受心脏移植的患者队列的精算生存率在1年、5年和10年时分别为79%、66%和49%。四个时代的受者年龄和性别分布有显著趋势，时代III和IV中年龄较大（> 60岁）和女性受者的比例增加（p = 0.001和0.02）。所有时代的早期死亡率和长期生存率均有显著改善（p < 0.001）。作为死亡原因的排斥反应随时间减少（时代I，24%；时代II，21%；时代III，15%；时代IV，9%；p = 0.02），而移植冠状动脉疾病作为死亡原因的贡献保持不变。
心脏移植为终末期心力衰竭患者提供了令人满意的长期生存。生存结果的改善与每个时代免疫抑制治疗的改善相关。虽然随着时间推移生存改善的原因是多因素的，但我们认为免疫抑制治疗的变化对生存产生了重大影响，这从因排斥反应导致的死亡人数减少可以看出。
