Mansfield Robert T, Lin Kimberly Y, Zaoutis Theoklis, Mott Antonio R, Mohamad Zeinab, Luan Xianqun, Kaufman Beth D, Ravishankar Chitra, Gaynor J William, Shaddy Robert E, Rossano Joseph W
1Cardiac Center, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 2Division of Pediatric Cardiology, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA. 3Department of Pediatric Cardiac Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.
Pediatr Crit Care Med. 2015 Jul;16(6):522-8. doi: 10.1097/PCC.0000000000000401.
The use of ventricular assist devices has increased dramatically in adult heart failure patients. However, the overall use, outcome, comorbidities, and resource utilization of ventricular assist devices in pediatric patients have not been well described. We sought to demonstrate that the use of ventricular assist devices in pediatric patients has increased over time and that mortality has decreased.
A retrospective study of the Pediatric Health Information System database was performed for patients 20 years old or younger undergoing ventricular assist device placement from 2000 to 2010.
None.
Four hundred seventy-five pediatric patients were implanted with ventricular assist devices during the study period: 69 in 2000-2003 (era 1), 135 in 2004-2006 (era 2), and 271 in 2007-2010 (era 3). Median age at ventricular assist device implantation was 6.0 years (interquartile range, 0.5-13.8), and the proportion of children who were 1-12 years old increased from 29% in era 1 to 47% in era 3 (p = 0.002). The majority of patients had a diagnosis of cardiomyopathy; this increased from 52% in era 1 to 72% in era 3 (p = 0.003). Comorbidities included arrhythmias (48%), pulmonary hypertension (16%), acute renal failure (34%), cerebrovascular disease (28%), and sepsis/systemic inflammatory response syndrome (34%). Two hundred forty-seven patients (52%) underwent heart transplantation and 327 (69%) survived to hospital discharge. Hospital mortality decreased from 42% in era 1 to 25% in era 3 (p = 0.004). Median hospital length of stay increased (37 d [interquartile range, 12-64 d] in era 1 vs 69 d [interquartile range, 35-130] in era 3; p < 0.001) and median adjusted hospital charges increased ($630,630 [interquartile range, $227,052-$853,318] in era 1 vs $1,577,983 [interquartile range, $874,463-$2,280,435] in era 3; p < 0.001). Factors associated with increased mortality include age less than 1 year (odds ratio, 2.04; 95% CI, 1.01-3.83), acute renal failure (odds ratio, 2.1; 95% CI, 1.26-3.65), cerebrovascular disease (odds ratio, 2.1; 95% CI, 1.25-3.62), and extracorporeal membrane oxygenation (odds ratio, 3.16; 95% CI, 1.79-5.60). Ventricular assist device placement in era 3 (odds ratio, 0.3; 95% CI, 0.15-0.57) and a diagnosis of cardiomyopathy (odds ratio, 0.5; 95% CI, 0.32-0.84), were associated with decreased mortality. Large-volume centers had lower mortality (odds ratio, 0.55; 95% CI, 0.34-0.88), lower use of extracorporeal membrane oxygenation, and higher charges.
The use of ventricular assist devices and survival after ventricular assist device placement in pediatric patients have increased over time, with a concomitant increase in resource utilization. Age under 1 year, certain noncardiac morbidities, and the use of extracorporeal membrane oxygenation are associated with worse outcomes. Lower mortality was seen at larger volume ventricular assist device centers.
成人心力衰竭患者使用心室辅助装置的情况急剧增加。然而，小儿患者使用心室辅助装置的总体情况、结局、合并症及资源利用情况尚未得到充分描述。我们试图证明小儿患者使用心室辅助装置的情况随时间增加，且死亡率降低。
对儿科健康信息系统数据库进行回顾性研究，纳入2000年至2010年接受心室辅助装置植入的20岁及以下患者。
无。
研究期间有475例小儿患者植入了心室辅助装置：2000 - 2003年（第1阶段）69例，2004 - 2006年（第2阶段）135例，2007 - 2010年（第3阶段）271例。心室辅助装置植入时的中位年龄为6.0岁（四分位间距，0.5 - 13.8），1 - 12岁儿童的比例从第1阶段的29%增至第3阶段的47%（p = 0.002）。大多数患者诊断为心肌病；这一比例从第1阶段的52%增至第3阶段的72%（p = 0.003）。合并症包括心律失常（48%）、肺动脉高压（16%）、急性肾衰竭（34%）、脑血管疾病（28%）及脓毒症/全身炎症反应综合征（34%）。247例患者（52%）接受了心脏移植，327例（69%）存活至出院。住院死亡率从第1阶段的42%降至第3阶段的25%（p = 0.004）。中位住院时间延长（第1阶段为37天[四分位间距，12 - 64天]，第3阶段为69天[四分位间距，35 - 130天]；p < 0.001），中位调整后住院费用增加（第1阶段为630,630美元[四分位间距，227,052 - 853,318美元]，第3阶段为1,577,983美元[四分位间距，874,463 - 2,280,435美元]；p < 0.001）。与死亡率增加相关的因素包括年龄小于1岁（比值比，2.04；95%可信区间，1.01 - 3.83）、急性肾衰竭（比值比，2.1；95%可信区间，1.26 - 3.65）、脑血管疾病（比值比，2.1；95%可信区间，1.25 - 3.62）及体外膜肺氧合（比值比，3.16；95%可信区间，1.79 - 5.60）。第3阶段植入心室辅助装置（比值比，0.3；95%可信区间，0.15 - 0.57）及诊断为心肌病（比值比，0.5；95%可信区间，0.32 - 0.84）与死亡率降低相关。大容量中心死亡率较低（比值比，0.55；95%可信区间，0.34 - 0.88），体外膜肺氧合使用较少，费用较高。
小儿患者使用心室辅助装置的情况及心室辅助装置植入后的生存率随时间增加，同时资源利用也增加。1岁以下年龄、某些非心脏合并症及体外膜肺氧合的使用与较差结局相关。大容量心室辅助装置中心死亡率较低。
