Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minn 55455, USA.
J Thorac Cardiovasc Surg. 2010 Jul;140(1):174-81. doi: 10.1016/j.jtcvs.2010.03.037. Epub 2010 May 5.
Although left ventricular assist devices (LVADs) are associated with excellent outcomes in patients with end-stage heart failure, there are conflicting reports on posttransplant survival in these patients. Furthermore, prior studies with pulsatile LVADs have shown that transplantation, either early (<6 weeks) or late (>6 months) after LVAD implantation, adversely affected post-cardiac transplant survival. We sought to determine factors related to posttransplant survival in patients supported with continuous-flow LVADs.
The HeartMate II LVAD (Thoratec Corporation, Pleasanton, Calif) was implanted in 468 patients as a bridge to transplant at 36 centers in a multicenter trial. Patients who underwent transplantation after support were stratified by demographics: gender, age, etiology, body mass index, duration of device support, and by adverse events during support. The median age was 54 years (range 18-73 years); 43% had ischemic etiology, and 18% were women. Survival was determined at the specific intervals of 30 days and 1 year after transplantation.
Of 468 patients, 250 (53%) underwent cardiac transplant after a median duration of LVAD support of 151 days (longest: 3.2 years), 106 (23%) died, 12 (2.6%) recovered ventricular function and the device was removed, and 100 (21%) were still receiving LVAD support. The overall 30-day and 1-year posttransplant survivals were 97% and 87%. There were no significant differences in survival based on demographic factors or LVAD duration of less than 30 days, 30 to 90 days, 90 to 180 days, and more than 180 days. Patients requiring more than 2 units of packed red blood cells in 24 hours during LVAD support had a statistically significant decreased 1-year survival (82% vs 94%) when compared with patients who did not require more than 2 units of packed red blood cells in 24 hours during LVAD support (P = .03). There was a trend for slightly lower survival at 1 year in patients with percutaneous lead infections during LVAD support versus no infection (75% vs 89%; P = .07).
Post-cardiac transplant survival in patients supported with continuous-flow devices such as the HeartMate II LVAD is equivalent to that with conventional transplantation. Furthermore, posttransplant survival is not influenced by the duration of LVAD support. The improved durability and reduced short- and long-term morbidity associated with the HeartMate II LVAD has reduced the need for urgent cardiac transplantation, which may have adversely influenced survival in the pulsatile LVAD era. This information may have significant implications for changing the current United Network for Organ Sharing criteria regarding listing of heart transplant candidates.
尽管左心室辅助装置（LVAD）可使终末期心力衰竭患者获得出色的治疗效果，但对于这些患者在移植后的生存情况，目前仍存在相互矛盾的报告。此外，先前采用搏动式 LVAD 的研究表明，LVAD 植入后早期（<6 周）或晚期（>6 个月）进行移植，会对心脏移植后的生存产生不利影响。我们旨在确定使用连续血流 LVAD 支持的患者移植后的生存相关因素。
在一项多中心试验中，468 例患者在 36 个中心接受了 HeartMate II LVAD（Thoratec 公司，加利福尼亚州普莱森顿）作为移植前的桥接治疗。根据患者的性别、年龄、病因、体重指数、设备支持时间以及支持期间的不良事件，将接受移植的患者按人口统计学特征进行分层。中位年龄为 54 岁（范围 18-73 岁）；43%的患者病因是缺血性的，18%是女性。在移植后特定的 30 天和 1 年时间点评估生存情况。
在 468 例患者中，250 例（53%）在接受 LVAD 支持的中位时间为 151 天后（最长 3.2 年）接受了心脏移植，106 例（23%）死亡，12 例（2.6%）恢复了心室功能并移除了设备，100 例（21%）仍在接受 LVAD 支持。总体 30 天和 1 年的移植后生存率分别为 97%和 87%。根据人口统计学因素或 LVAD 支持时间<30 天、30-90 天、90-180 天和>180 天，生存率没有显著差异。在 LVAD 支持期间需要 2 单位以上浓缩红细胞的患者与不需要 2 单位以上浓缩红细胞的患者相比，1 年生存率有显著下降（82%对 94%）（P =.03）。与无感染的患者相比，在 LVAD 支持期间发生经皮导线感染的患者 1 年生存率略低（75%对 89%；P =.07）。
接受 HeartMate II LVAD 等连续血流装置支持的患者的心脏移植后生存率与传统移植相当。此外，LVAD 支持时间对移植后生存没有影响。HeartMate II LVAD 具有更好的耐用性和降低的短期和长期发病率，减少了紧急心脏移植的需求，这可能对搏动式 LVAD 时代的生存产生了不利影响。这些信息可能对改变目前关于心脏移植候选者名单的美国器官共享网络标准具有重要意义。
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