Department of Cardiothoracic Surgery, Stanford University/Lucille Packard Children's Hospital, Palo Alto, California, USA.
Ann Surg. 2011 Feb;253(2):393-401. doi: 10.1097/SLA.0b013e31820700cc.
The relationship between volume and outcome in many complex surgical procedures is well established.
No published data has examined this relationship in pediatric cardiac transplantation, but low-volume adult heart transplant programs seem to have higher early mortality.
The United Network for Organ Sharing (UNOS) provided center-specific data for the 4647 transplants performed on patients younger than 19 years old, 1992 to 2007. Patients were stratified into 3 groups based on the volume of transplants performed in the previous 5 years at that center: low [<19 transplants, n = 1135 (24.4%)], medium [19–62 transplants, n = 2321(50.0%)], and high [≥63 transplants, n= 1191 (25.6%)]. A logistic regression model for postoperative mortality was developed and observed-to-expected (O:E) mortality rates calculated for each group.
Unadjusted long-term survival decreased with decreasing center volume (P<0.0001). Observed postoperative mortality was higher than expected at low-volume centers [O:E ratio 1.39, 95% confidence interval (CI) 1.05–1.83]. At low volume centers, high-risk patients (1.34, 0.85–2.12)--especially patients 1 year old or younger (1.60, 1.07–2.40) or those with congenital heart disease (1.36, 0.94–1.96)--did poorly, but those at high-volume centers did well (congenital heart disease: 0.90, 0.36–1.26; age<1 year: 0.75, 0.51–1.09). Similar results were obtained in the subset of patients transplanted after 1996. In multivariate logistic regression modeling, transplantation at a low-volume center was associated with an odds ratio for postoperative mortality of 1.60 (95% CI, 1.14–2.24); transplantation at a medium volume center had an odds ratio of 1.24 (95% CI, 0.92–1.66).
The volume of transplants performed at any one center has a significant impact on outcomes. Regionalization of care is one option for improving outcomes in pediatric cardiac transplantation.
许多复杂手术中，术量与结果之间的关系已经得到充分证实。
虽然目前尚无文献研究术量与小儿心脏移植结果之间的关系，但成人心脏移植低容量中心的早期死亡率似乎更高。
美国器官共享网络（UNOS）提供了 1992 年至 2007 年期间 4647 例年龄小于 19 岁患者的中心特异性数据。患者按前 5 年中心移植例数分为 3 组：低容量[＜19 例，n=1135（24.4%）]、中容量[19～62 例，n=2321（50.0%）]和高容量[≥63 例，n=1191（25.6%）]。建立了术后死亡率的逻辑回归模型，并计算了每组的观察到的与预期的（O：E）死亡率。
未校正的长期生存率随中心术量减少而降低（P＜0.0001）。低容量中心的术后观察死亡率高于预期（O：E 比值 1.39，95%置信区间[CI]1.05～1.83）。在低容量中心，高危患者（1.34，0.85～2.12）——尤其是 1 岁或以下的患者（1.60，1.07～2.40）或患有先天性心脏病的患者（1.36，0.94～1.96）——预后较差，但高容量中心的患者预后良好（先天性心脏病：0.90，0.36～1.26；年龄＜1 岁：0.75，0.51～1.09）。在 1996 年后移植的患者亚组中也得到了类似的结果。多变量逻辑回归模型显示，低容量中心移植的术后死亡率比值比（OR）为 1.60（95%CI，1.14～2.24）；中容量中心移植的 OR 为 1.24（95%CI，0.92～1.66）。
任何一个中心的移植术量都对结果有显著影响。小儿心脏移植结果的改善可以选择区域化治疗。
