Awad M, Czer L S C, De Robertis M A, Mirocha J, Ruzza A, Rafiei M, Reich H, Trento A, Moriguchi J, Kobashigawa J, Esmailian F, Arabia F, Ramzy D
Division of Cardiology, Cedars Sinai Heart Institute, Los Angeles, California, USA.
Division of Cardiology, Cedars Sinai Heart Institute, Los Angeles, California, USA.
Transplant Proc. 2016 Jan-Feb;48(1):158-66. doi: 10.1016/j.transproceed.2015.12.007.
The impact of prior implantation of a ventricular assist device (VAD) on short- and long-term postoperative outcomes of adult heart transplantation (HTx) was investigated.
Of the 359 adults with prior cardiac surgery who underwent HTx from December 1988 to June 2012 at our institution, 90 had prior VAD and 269 had other (non-VAD) prior cardiac surgery.
The VAD group had a lower 60-day survival when compared with the Non-VAD group (91.1% ± 3.0% vs 96.6% ± 1.1%; P = .03). However, the VAD and Non-VAD groups had similar survivals at 1 year (87.4% ± 3.6% vs 90.5% ± 1.8%; P = .33), 2 years (83.2% ± 4.2% vs 88.1% ± 2.0%; P = .21), 5 years (75.7% ± 5.6% vs 74.6% ± 2.9%; P = .63), 10 years (38.5% ± 10.8% vs 47.6% ± 3.9%; P = .33), and 12 years (28.9% ± 11.6% vs 39.0% ± 4.0%; P = .36). The VAD group had longer pump time and more intraoperative blood use when compared with the Non-VAD group (P < .0001 for both). Postoperatively, VAD patients had higher frequencies of >48-hour ventilation and in-hospital infections (P = .0007 and .002, respectively). In addition, more VAD patients had sternal wound infections when compared with Non-VAD patients (8/90 [8.9%] vs 5/269 [1.9%]; P = .005). Both groups had similar lengths of intensive care unit (ICU) and hospital stays and no differences in the frequencies of reoperation for chest bleeding, dialysis, and postdischarge infections (P = .19, .70, .34, .67, and .21, respectively). Postoperative creatinine levels at peak and at discharge did not differ between the 2 groups (P = .51 and P = .098, respectively). In a Cox model, only preoperative creatinine ≥1.5 mg/dL (P = .006) and intraoperative pump time ≥210 minutes (P = .022) were individually considered as significant predictors of mortality within 12 years post-HTx. Adjusting for both, pre-HTx VAD implantation was not a predictor of mortality within 12 years post-HTx (hazard ratio [HR], 1.23; 95% confidence interval [CI], 0.77-1.97; P = .38). However, pre-HTx VAD implantation was a risk factor for 60-day mortality (HR, 2.86; 95% CI, 1.07-7.62; P = .036) along with preoperative creatinine level ≥2 mg/dL (P = .0006).
HTx patients with prior VAD had lower 60-day survival, higher intraoperative blood use, and greater frequency of postoperative in-hospital infections when compared with HTx patients with prior Non-VAD cardiac surgery. VAD implantation prior to HTx did not have an additional negative impact on long-term morbidity and survival following HTx. Long-term (1-, 2-, 5-, 10-, and 12-year) survival did not differ significantly in HTx patients with prior VAD or non-VAD cardiac surgery.
研究既往植入心室辅助装置（VAD）对成人心脏移植（HTx）术后短期和长期结局的影响。
1988年12月至2012年6月在本机构接受HTx的359例既往有心脏手术史的成人中，90例既往植入过VAD，269例既往接受过其他（非VAD）心脏手术。
与非VAD组相比，VAD组60天生存率较低（91.1%±3.0%对96.6%±1.1%；P = 0.03）。然而，VAD组和非VAD组在1年（87.4%±3.6%对90.5%±1.8%；P = 0.33）、2年（83.2%±4.2%对88.1%±2.0%；P = 0.21）、5年（75.7%±5.6%对74.6%±2.9%；P = 0.63）、10年（38.5%±10.8%对47.6%±3.9%；P = 0.33）和12年（28.9%±11.6%对39.0%±4.0%；P = 0.36）时的生存率相似。与非VAD组相比，VAD组的体外循环时间更长，术中输血量更多（两者P均<0.0001）。术后，VAD患者48小时以上通气和院内感染的发生率更高（分别为P = 0.0007和0.002）。此外，与非VAD患者相比，VAD患者胸骨伤口感染更多（8/90[8.9%]对5/269[1.9%]；P = 0.005）。两组的重症监护病房（ICU）住院时间和住院总时长相似，胸部出血再次手术、透析及出院后感染的发生率无差异（分别为P = 0.19、0.70、0.34、0.67和0.21）。两组术后肌酐峰值水平和出院时肌酐水平无差异（分别为P = 0.51和P = 0.098）。在Cox模型中，仅术前肌酐≥1.5mg/dL（P = 0.006）和术中体外循环时间≥210分钟（P = 0.022）被单独视为HTx术后12年内死亡的显著预测因素。对两者进行校正后，HTx术前植入VAD并非HTx术后12年内死亡的预测因素（风险比[HR]，1.23；95%置信区间[CI]，0.77 - 1.97；P = 0.38）。然而，HTx术前植入VAD与术前肌酐水平≥2mg/dL一样，是60天死亡的危险因素（HR，2.86；95%CI，1.07 - 7.62；P = 0.036）。
与既往有非VAD心脏手术史的HTx患者相比，既往植入VAD的HTx患者60天生存率较低，术中输血量更多，术后院内感染发生率更高。HTx术前植入VAD对HTx术后长期发病率和生存率没有额外的负面影响。既往植入VAD或非VAD心脏手术的HTx患者的长期（1年、2年、5年、10年和12年）生存率无显著差异。
