Khera Rohan, Cram Peter, Lu Xin, Vyas Ankur, Gerke Alicia, Rosenthal Gary E, Horwitz Phillip A, Girotra Saket
Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City.
Department of Medicine, University of Toronto, Toronto, Ontario, Canada3Division of General Internal Medicine, University Health Network/Mt Sinai Hospitals, Toronto, Ontario, Canada.
JAMA Intern Med. 2015 Jun;175(6):941-50. doi: 10.1001/jamainternmed.2014.7856.
Percutaneous ventricular assist devices (PVADs) provide robust hemodynamic support compared with intra-aortic balloon pumps (IABPs), but clinical use patterns are unknown.
To examine contemporary patterns in PVAD use in the United States and compare them with use of IABPs.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of adults older than 18 years who received a PVAD or IABP while hospitalized in the United States (2007-2012).
Temporal trends in utilization, patient and hospital characteristics, in-hospital mortality, and cost of PVAD use compared with IABP.
During 2007 through 2012, utilization of PVADs increased 30-fold (4.6 per million discharges in 2007 to 138 per million discharges in 2012; P for trend < .001) while utilization of IABPs decreased from 1738 per million discharges in 2008 to 1608 per million discharges in 2012 (P for trend = .02). In 2007, an estimated 72 hospitals used PVADs, increasing to 477 in 2011 (P for trend < .001). The number of hospitals with an annual volume of 10 or more PVAD procedures per year increased from 0 in 2007 to 102 in 2011 (21.4% of PVAD-using hospitals; P for trend < .001). Among PVAD recipients, 67.3% had a diagnosis of cardiogenic shock or acute myocardial infarction (AMI). There was a temporal increase in the use of PVADs in older patients and patients with AMI, hypertension, diabetes mellitus, and chronic kidney disease (P for trend < .001 for all). Overall, mortality in PVAD recipients was 28.8%, and mean (SE) hospitalization cost was $85,580 ($4165); both were significantly higher in PVAD recipients with cardiogenic shock (mortality, 47.5%; mean [SE] cost, $113,695 [$6260]; P < .001 for both). The PVAD recipients were less likely than IABP recipients to have cardiogenic shock (34.3% vs 41.2%; P = .001), AMI (48.0% vs 68.6%; P < .001), and undergo coronary artery bypass graft surgery (6.2% vs 43.2%; P < .001), but more likely to undergo percutaneous coronary intervention (70.9% vs 40.4%; P < .001). In propensity-matched analysis, PVADs were associated with higher mortality compared with IABP (odds ratio, 1.23 [95% CI, 1.06-1.43]; P = .007).
There has been a substantial increase in the use of PVADs in recent years with an accompanying decrease in the use of IABPs. Given the high mortality, associated cost, and uncertain evidence for a clear benefit, randomized clinical trials are needed to determine whether use of PVADs leads to improved patient outcomes.
与主动脉内球囊反搏（IABP）相比，经皮心室辅助装置（PVAD）能提供强大的血流动力学支持，但临床使用模式尚不清楚。
研究美国PVAD的当代使用模式，并将其与IABP的使用情况进行比较。
设计、设置和参与者：对2007 - 2012年在美国住院期间接受PVAD或IABP的18岁以上成年人进行回顾性研究。
与IABP相比，PVAD使用的时间趋势、患者和医院特征、住院死亡率及成本。
在2007年至2012年期间，PVAD的使用量增加了30倍（从2007年每百万出院患者中的4.6例增至2012年的每百万出院患者中的138例；趋势P值<0.001），而IABP的使用量从2008年每百万出院患者中的1738例降至2012年的每百万出院患者中的1608例（趋势P值=0.02）。2007年，估计有72家医院使用PVAD，到2011年增至477家（趋势P值<0.001）。每年进行10例或更多PVAD手术的医院数量从2007年的0家增至2011年的102家（占使用PVAD医院的21.4%；趋势P值<0.001）。在接受PVAD的患者中，67.3%被诊断为心源性休克或急性心肌梗死（AMI）。老年患者以及患有AMI、高血压、糖尿病和慢性肾脏病的患者使用PVAD的情况呈时间上升趋势（所有趋势P值<0.001）。总体而言，接受PVAD患者的死亡率为28.8%，平均（SE）住院费用为85,580美元（4165美元）；在心源性休克的PVAD接受者中，这两项指标均显著更高（死亡率47.5%；平均[SE]费用113,695美元[6260美元]；两者P值<0.001）。与IABP接受者相比，PVAD接受者发生心源性休克（34.3%对41.2%；P = 0.001）、AMI（48.0%对68.6%；P < 0.001）以及接受冠状动脉旁路移植手术（6.2%对43.2%；P < 0.001）的可能性较小，但接受经皮冠状动脉介入治疗的可能性更大（70.9%对40.4%；P < 0.001）。在倾向匹配分析中，与IABP相比，PVAD与更高的死亡率相关（优势比，1.23[95%CI，1.06 - 1.43]；P = 0.007）。
近年来PVAD的使用大幅增加，同时IABP的使用减少。鉴于高死亡率、相关成本以及明确获益的证据不确定，需要进行随机临床试验以确定使用PVAD是否能改善患者预后。
