Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
Labatt Family Heart Centre, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.
J Thorac Cardiovasc Surg. 2014 Jul;148(1):282-9. doi: 10.1016/j.jtcvs.2014.03.022. Epub 2014 Mar 20.
Despite improved long-term survival after pediatric heart transplantation, perioperative mortality has remained high. We sought to understand the factors associated with perioperative graft loss after pediatric heart transplantation.
The factors associated with primary heart transplant mortality and retransplantation before hospital discharge in 226 pediatric heart transplant recipients (1995-2010) at a single-center institution were analyzed using multivariable logistic regression models adjusted for age at surgery and year of surgery.
A total of 26 patients died (n = 21) or underwent retransplantion (n = 5) before hospital discharge secondary to primary graft failure (n = 10), multisystem organ failure (n = 5), infection (n = 4), rejection (n = 2), and perioperative complications (n = 5). United Network for Organ Sharing status 1 (vs status 2) at transplantation was associated with an increased odds of death from noncardiac causes (odd ratio [OR], 4.7; 95% confidence level [CI], 1.2-22.3; P = .002). The factors associated with increased odds of perioperative mortality or retransplant were pre- and post-transplant extracorporeal membrane oxygenation (OR, 5.3; 95% CI, 1.5-18.7; P = .01; and OR, 25.9; 95% CI, 7.0-95.9; P < .001), longer ischemic times (OR, 1.4 per 30 minutes; 95% CI, 1.0-2.0; P = .04), reoperation after transplantation (OR, 3.5; 95% CI, 1.2-10.4; P = .02), and transplantation before 2002 (OR, 4.5; 95% CI, 1.4-14.9; P = .01), respectively.
The use of extracorporeal membrane oxygenation (both before and after transplantation), a longer ischemic time, and reoperation were key factors associated with perioperative graft loss, with noncardiac mortality closely related to United Network for Organ Sharing status at heart transplantation. Knowledge of the perioperative risk factors and how they affect graft survival will help guide difficult decisions around eligibility, timing of primary listing, and appropriateness for retransplantation, and potentially affect long-term survival.
尽管儿科心脏移植后的长期存活率有所提高，但围手术期死亡率仍然很高。我们试图了解与儿科心脏移植后围手术期移植物丢失相关的因素。
使用多变量逻辑回归模型分析了 226 例在单中心机构接受心脏移植的儿科患者（1995-2010 年）在手术时的年龄和手术年份调整后，与心脏移植后主要死亡和出院前再次移植相关的因素。
共有 26 例患者（n=21）因原发性移植物衰竭（n=10）、多系统器官衰竭（n=5）、感染（n=4）、排斥（n=2）和围手术期并发症（n=5）死亡或出院前再次移植。移植时联合器官共享网络状态 1（与状态 2 相比）与非心脏原因死亡的几率增加相关（比值比[OR]，4.7；95%置信区间[CI]，1.2-22.3；P=0.002）。与围手术期死亡或再次移植几率增加相关的因素包括移植前和移植后的体外膜氧合（OR，5.3；95%CI，1.5-18.7；P=0.01；和 OR，25.9；95%CI，7.0-95.9；P<0.001）、较长的缺血时间（OR，每 30 分钟增加 1.4；95%CI，1.0-2.0；P=0.04）、移植后的再次手术（OR，3.5；95%CI，1.2-10.4；P=0.02）和 2002 年前的移植（OR，4.5；95%CI，1.4-14.9；P=0.01）。
体外膜氧合（移植前后均有）、较长的缺血时间和再次手术是与围手术期移植物丢失相关的关键因素，非心脏死亡率与心脏移植时联合器官共享网络的状态密切相关。了解围手术期的危险因素以及它们如何影响移植物的存活，将有助于指导在资格、初次登记的时机和再次移植的适当性方面的困难决策，并可能影响长期存活。
