Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York, USA.
Ann Thorac Surg. 2011 Aug;92(2):520-7; discussion 527. doi: 10.1016/j.athoracsur.2011.02.086. Epub 2011 Jun 17.
In this study we sought the following: (1) To objectively assess the risk related to various pretransplant recipient and donor characteristics; (2) to devise a preoperative risk stratification score (RSS) based on pretransplant recipient and donor characteristics predicting graft loss at 1 year; and (3) to define different risk strata based on RSS.
The United Network for Organ Sharing provided de-identified patient-level data. Analysis included 11,703 orthotopic heart transplant recipients aged 18 years or greater and transplanted between January 1, 2001 and December 31, 2007. The primary outcome was 1-year graft failure. Multivariable logistic regression analysis (backward p value<0.20) was used to determine the relationship between pretransplant characteristics and 1-year graft failure. Using the odds ratio for each identified variable, an RSS was devised. The RSS strata were defined by calculating receiver operating characteristic curves and stratum specific likelihood ratios.
The strongest negative predictors of 1-year graft failure included the following: right ventricular assist device only, extracorporeal membrane oxygenation, renal failure, extracorporeal left ventricular assist device, total artificial heart, and advanced age. Threshold analysis identified 5 discrete RSS strata: low risk (LR, RSS: <2.55; n=3242, 27.7%), intermediate risk (IR, RSS: 2.55-5.72; n=6,347, 54.2%), moderate risk (MR, RSS: 5.73-8.13; n=1,543, 13.2%), elevated risk (ER, RSS: 8.14-9.48; n=310, 2.6%), and high risk (HR, RSS: >9.48; n=261, 2.2%). The 1-year actuarial survival (%) in the LR, IR, MR, ER, and HR groups were 93.8, 89.2, 81.3, 67.0, and 47.0, respectively.
Pretransplant recipient variables significantly influence early and late graft failure after heart transplantation. The RSS may improve organ allocation strategies by reducing the potential negative impact of transplanting candidates who are at a high risk for poor postoperative outcomes.
本研究旨在：（1）客观评估各种移植前受者和供者特征相关的风险；（2）基于移植前受者和供者特征制定术前风险分层评分（RSS），预测 1 年移植物失功；（3）基于 RSS 定义不同的风险分层。
美国器官共享网络提供了去标识化的患者水平数据。分析纳入了 2001 年 1 月 1 日至 2007 年 12 月 31 日期间年龄≥18 岁接受了原位心脏移植的 11703 例患者。主要结局为 1 年移植物失功。多变量逻辑回归分析（向后 p 值<0.20）用于确定移植前特征与 1 年移植物失功之间的关系。利用每个确定变量的比值比，制定 RSS。通过计算接受者操作特征曲线和分层特异性似然比来定义 RSS 分层。
1 年移植物失功的最强负预测因素包括以下内容：仅右心室辅助装置、体外膜肺氧合、肾衰竭、体外左心室辅助装置、全人工心脏和高龄。阈值分析确定了 5 个离散的 RSS 分层：低危（LR，RSS：<2.55；n=3242，27.7%）、中危（IR，RSS：2.55-5.72；n=6347，54.2%）、中高危（MR，RSS：5.73-8.13；n=1543，13.2%）、高危（ER，RSS：8.14-9.48；n=310，2.6%）和极高危（HR，RSS：>9.48；n=261，2.2%）。LR、IR、MR、ER 和 HR 组的 1 年累积生存率（%）分别为 93.8、89.2、81.3、67.0 和 47.0。
移植前受者变量显著影响心脏移植后的早期和晚期移植物失功。RSS 可以通过减少移植候选者术后不良结局风险较高的潜在负面影响来改善器官分配策略。
