Miller Jacob R, Simpson Kathleen E, Epstein Deirdre J, Lancaster Timothy S, Henn Matthew C, Schuessler Richard B, Balzer David T, Shahanavaz Shabana, Murphy Joshua J, Canter Charles E, Eghtesady Pirooz, Boston Umar S
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
Section of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA.
J Heart Lung Transplant. 2016 Jul;35(7):877-83. doi: 10.1016/j.healun.2016.02.005. Epub 2016 Mar 10.
Patients with a failing Fontan continue to have decreased survival after heart transplant (HT), particularly those with preserved ventricular function (PVF) compared with impaired ventricular function (IVF). In this study we evaluated the effect of institutional changes on post-HT outcomes.
Data were retrospectively collected for all Fontan patients who underwent HT. Mode of failure was defined by the last echocardiogram before HT, with mild or no dysfunction considered PVF and moderate or severe considered IVF. Outcomes were compared between early era (EE, 1995 to 2008) and current era (CE, 2009 to 2014). Management changes in the CE included volume load reduction with aortopulmonary collateral (APC) embolization, advanced cardiothoracic imaging, higher goal donor/recipient weight ratio and aggressive monitoring for post-HT vasoplegia.
A total of 47 patients were included: 27 in the EE (13 PVF, 14 IVF) and 20 in the CE (12 PVF, 8 IVF). Groups were similar pre-HT, except for more PLE in PVF patients. More patients underwent APC embolization in the CE (80% vs 28%, p < 0.01). There was no difference in donor/recipient weight ratio between eras. There was a trend toward higher primary graft failure for PVF in the EE (77% vs 36%, p = 0.05) but not the CE (42% vs 75%, p = 0.20). Overall, 1-year survival improved in the CE (90%) from the EE (63%) (p = 0.05), mainly due to increased survival for PVF (82 vs 38%, p = 0.04).
Post-HT survival for failing Fontan patients has improved, particularly for PVF. In the CE, our Fontan patients had a 1-year post-HT survival similar to other indications.
接受心脏移植（HT）后，Fontan手术失败的患者生存率持续降低，尤其是与心室功能受损（IVF）的患者相比，心室功能保留（PVF）的患者。在本研究中，我们评估了机构变革对HT术后结局的影响。
回顾性收集所有接受HT的Fontan患者的数据。失败模式根据HT前最后一次超声心动图确定，轻度功能障碍或无功能障碍视为PVF，中度或重度功能障碍视为IVF。比较早期（EE，1995年至2008年）和当前时期（CE，2009年至2014年）的结局。CE期的管理变革包括通过主动脉肺侧支（APC）栓塞减轻容量负荷、先进的心胸成像、更高的供体/受体体重比目标以及对HT后血管麻痹的积极监测。
共纳入47例患者：EE期27例（13例PVF，14例IVF），CE期20例（12例PVF，8例IVF）。HT前两组相似，但PVF患者的胸腔积液更多。CE期接受APC栓塞的患者更多（80%对28%，p<0.01）。不同时期的供体/受体体重比无差异。EE期PVF患者原发性移植物失败率有升高趋势（77%对36%，p=0.05），但CE期无此趋势（42%对75%，p=0.20）。总体而言，CE期的1年生存率从EE期的63%提高到了90%（p=0.05），主要是由于PVF患者生存率提高（82%对38%，p=0.04）。
Fontan手术失败患者的HT术后生存率有所提高，尤其是PVF患者。在CE期，我们的Fontan患者HT术后1年生存率与其他适应症相似。
