Grimm Joshua C, Magruder J Trent, Crawford Todd C, Fraser Charles D, Plum William G, Sciortino Christopher M, Higgins Robert S, Whitman Glenn J R, Shah Ashish S
Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
Ann Thorac Surg. 2016 Oct;102(4):1206-12. doi: 10.1016/j.athoracsur.2016.04.022. Epub 2016 Jun 17.
The aim of this study was to determine whether the duration of left ventricular device support (LVAD) influenced outcomes after orthotopic heart transplantation in a modern, bridge to transplant national cohort.
The United Network for Organ Sharing database, which has recently made pretransplant LVAD duration available, was queried for all adult bridge to transplant patients between January 2011 and December 2012. Three LVAD duration cohorts were generated, as follows: short (less than 90 days), intermediate (90 to 365 days), and prolonged (more than 365 days). Recipient, donor, and transplant-specific characteristics were compared among the duration cohorts. Unadjusted short-term and long-term survivals were estimated with the Kaplan-Meier method. Risk-adjusted models were also constructed to determine the independent impact of device duration on mortality.
Of the 1,332 patients who met criteria for inclusion, 9.8% (n = 130), 54.7% (n = 729), and 35.5% (n = 473) were classified as short, intermediate, and prolonged, respectively. Although the performance status across each cohort was similar at listing (p = 0.38), more patients in the intermediate and prolonged cohorts were considered functionally independent before orthotopic heart transplantation (32% and 37%, respectively, versus 18%; p < 0.001). Additionally, despite worse baseline renal function in the intermediate and prolonged cohorts relative to the short cohort (glomerular filtration rate, 57 and 57 versus 69, p < 0.001), there was no difference in the incidence of new onset posttransplant renal failure (7% versus 10%, 9%, p = 0.41). There was also no difference in 30-day survival (98%, 96%, 95%, p = 0.51), 6-month survival (93%, 92%, 92%, p = 0.93), or 1-year survival (91%, 89%, 89%, p = 0.78) across the cohorts. After risk adjustment, duration did not independently predict mortality at any timepoint.
In the largest, non-industry sponsored study of a modern bridge to transplant cohort, we demonstrated that duration of LVAD support before orthotopic heart transplantation does not influence posttransplant morbidity or mortality. In subanalysis, support for 90 days or more is associated with improvements in pretransplant functional performance.
本研究的目的是确定在一个现代的全国性心脏移植过渡队列中，左心室辅助装置（LVAD）支持的持续时间是否会影响原位心脏移植后的结局。
查询器官共享联合网络数据库，该数据库最近提供了移植前LVAD支持的持续时间信息，纳入2011年1月至2012年12月期间所有成年心脏移植过渡患者。生成了三个LVAD支持持续时间队列，如下：短期（少于90天）、中期（90至365天）和长期（超过365天）。比较各持续时间队列之间受者、供者及移植相关特征。采用Kaplan-Meier法估计未调整的短期和长期生存率。还构建了风险调整模型以确定装置支持持续时间对死亡率的独立影响。
在符合纳入标准的1332例患者中，分别有9.8%（n = 130）、54.7%（n = 729）和35.5%（n = 473）被分类为短期、中期和长期。尽管各队列在登记时的功能状态相似（p = 0.38），但中期和长期队列中更多患者在原位心脏移植前被认为功能独立（分别为32%和37%，而短期队列中为18%；p < 0.001）。此外，尽管中期和长期队列的基线肾功能相对于短期队列较差（肾小球滤过率分别为57、57和69，p < 0.001），但移植后新发肾衰竭的发生率并无差异（分别为7%、10%、9%，p = 0.41）。各队列在30天生存率（98%、96%、95%，p = 0.51）、6个月生存率（93%、92%、92%，p = 0.93）或1年生存率（91%、89%、89%，p = 0.78）方面也无差异。经过风险调整后，在任何时间点，支持持续时间均不能独立预测死亡率。
在最大规模的、非行业资助的现代心脏移植过渡队列研究中，我们证明原位心脏移植前LVAD支持的持续时间不会影响移植后的发病率或死亡率。在亚组分析中，90天或更长时间的支持与移植前功能表现的改善相关。
