Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, 9500 Euclid Avenue/Mail Stop J4-1, Cleveland, OH 44195, USA.
J Thorac Cardiovasc Surg. 2010 Mar;139(3):765-773.e1. doi: 10.1016/j.jtcvs.2009.09.031.
The study objectives were to (1) compare survival after lung transplantation in patients requiring pretransplant mechanical ventilation or extracorporeal membrane oxygenation with that of patients not requiring mechanical support and (2) identify risk factors for mortality.
Data were obtained from the United Network for Organ Sharing for lung transplantation from October 1987 to January 2008. A total of 15,934 primary transplants were performed: 586 in patients on mechanical ventilation and 51 in patients on extracorporeal membrane oxygenation. Differences between nonsupport patients and those on mechanical ventilation or extracorporeal membrane oxygenation support were expressed as 2 propensity scores for use in comparing risk-adjusted survival.
Unadjusted survival at 1, 6, 12, and 24 months was 83%, 67%, 62%, and 57% for mechanical ventilation, respectively; 72%, 53%, 50%, and 45% for extracorporeal membrane oxygenation, respectively; and 93%, 85%, 79%, and 70% for unsupported patients, respectively (P < .0001). Recipients on mechanical ventilation were younger, had lower forced vital capacity, and had diagnoses other than emphysema. Recipients on extracorporeal membrane oxygenation were also younger, had higher body mass index, and had diagnoses other than cystic fibrosis/bronchiectasis. Once these variables, transplant year, and propensity for mechanical support were accounted for, survival remained worse after lung transplantation for patients on mechanical ventilation and extracorporeal membrane oxygenation.
Although survival after lung transplantation is markedly worse when preoperative mechanical support is necessary, it is not dismal. Thus, additional risk factors for mortality should be considered when selecting patients for lung transplantation to maximize survival. Reduced survival for this high-risk population raises the important issue of balancing maximal individual patient survival against benefit to the maximum number of patients.
本研究旨在（1）比较需要进行移植前机械通气或体外膜肺氧合的患者与无需机械支持的患者在肺移植后的生存情况，（2）确定死亡的风险因素。
研究数据来自 1987 年 10 月至 2008 年 1 月期间美国器官共享网络的肺移植数据。共进行了 15934 例原发性移植手术：586 例患者在机械通气下进行，51 例患者在体外膜肺氧合下进行。非支持组与机械通气或体外膜肺氧合支持组之间的差异用 2 个倾向评分来表示，以用于比较风险调整后的生存情况。
未调整的 1、6、12 和 24 个月生存率分别为机械通气组 83%、67%、62%和 57%，体外膜肺氧合组 72%、53%、50%和 45%，未支持组 93%、85%、79%和 70%（P<.0001）。接受机械通气的患者更年轻，用力肺活量较低，且诊断为除肺气肿以外的疾病。接受体外膜肺氧合的患者也更年轻，体重指数较高，且诊断为除囊性纤维化/支气管扩张以外的疾病。在考虑了这些变量、移植年份和机械支持倾向后，接受机械通气和体外膜肺氧合的患者肺移植后的生存率仍然较差。
尽管术前需要机械支持的患者肺移植后的生存率明显较差，但并非没有希望。因此，在选择肺移植患者时，应考虑其他死亡风险因素，以最大限度地提高生存率。对于这一高危人群来说，生存率降低提出了一个重要问题，即需要在最大化个体患者生存与使最大多数患者受益之间取得平衡。
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