Division of Cardiac Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
Ann Thorac Surg. 2012 Dec;94(6):2025-32. doi: 10.1016/j.athoracsur.2012.07.039. Epub 2012 Sep 7.
Although several studies have examined factors affecting survival after orthotopic heart transplantation (OHT), few have evaluated the impact of reoperative sternotomy. We undertook this study to examine the incidence and impact of repeat sternotomies on OHT outcomes.
We conducted a retrospective review of all adult OHT from 2 institutions. Primary stratification was by the number of prior sternotomies. The primary outcome was survival. Secondary outcomes included blood product utilization and commonly encountered postoperative complications. Multivariable Cox proportional hazards regression models examined mortality while linear regression models examined blood utilization.
From January 1995 to October 2011, 631 OHT were performed. Of these, 25 (4.0%) were redo OHT and 182 (28.8%) were bridged to transplant with a ventricular assist device; 356 (56.4%) had undergone at least 1 prior sternotomy. On unadjusted analysis, reoperative sternotomy was associated with decreased 90-day (98.5% vs 90.2%, p<0.001), 1-year (93.1% vs 79.6%, p<0.001), and 5-year (80.4% vs 70.1%, p=0.002) survival. This difference persisted on multivariable analysis at 90 days (hazard ratio [HR] 2.99, p=0.01), 1 year (HR 2.98, p=0.002), and 5 years (HR 1.62, p=0.049). The impact of an increasing number of prior sternotomies was negligible. On multivariable analysis, an increasing number of prior sternotomies was associated with increased intraoperative blood product utilization. Increasing blood utilization was associated with decreased 90-day, 1-year, and 5-year survival.
Reoperative sternotomy is associated with increased mortality and blood utilization after OHT. Patients with more than 1 prior sternotomy do not experience additional increased mortality. Carefully selected patients with multiple prior sternotomies have decreased but acceptable outcomes.
虽然有几项研究探讨了影响原位心脏移植（OHT）后生存率的因素，但很少有研究评估再次开胸的影响。我们进行这项研究是为了评估再次开胸对 OHT 结果的影响。
我们对 2 家机构的所有成人 OHT 进行了回顾性研究。主要分层是根据先前开胸次数。主要结果是生存率。次要结果包括血液制品的使用和常见的术后并发症。多变量 Cox 比例风险回归模型检查死亡率，线性回归模型检查血液使用量。
从 1995 年 1 月至 2011 年 10 月，共进行了 631 例 OHT。其中，25 例（4.0%）为再次 OHT，182 例（28.8%）使用心室辅助装置桥接至移植；356 例（56.4%）至少进行过一次先前的开胸手术。在未调整的分析中，再次开胸与 90 天（98.5%比 90.2%，p<0.001）、1 年（93.1%比 79.6%，p<0.001）和 5 年（80.4%比 70.1%，p=0.002）的生存率降低有关。在 90 天（风险比[HR]2.99，p=0.01）、1 年（HR2.98，p=0.002）和 5 年（HR1.62，p=0.049）时，这种差异在多变量分析中仍然存在。先前开胸次数的增加影响可忽略不计。在多变量分析中，先前开胸次数的增加与术中血液制品使用量的增加相关。血液利用量的增加与 90 天、1 年和 5 年的生存率降低相关。
再次开胸与 OHT 后死亡率和血液利用量的增加有关。有超过 1 次开胸史的患者不会经历额外的死亡率增加。精心选择有多次开胸史的患者，可获得降低但可接受的结果。
