Takeda Koji, Li Boyangzi, Garan Arthur R, Topkara Veli K, Han Jiho, Colombo Paolo C, Farr Maryjane A, Naka Yoshifumi, Takayama Hiroo
Division of Cardiothoracic Surgery, Department of Surgery, New York, New York.
Division of Cardiothoracic Surgery, Department of Surgery, New York, New York.
J Heart Lung Transplant. 2017 Jun;36(6):650-656. doi: 10.1016/j.healun.2016.12.006. Epub 2016 Dec 23.
Primary graft dysfunction (PGD) is one of the most common causes of early death after orthotopic heart transplantation. Mechanical circulatory support devices are required for severe forms of PGD. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) and temporary ventricular assist device (VAD) support have both been reported to be useful for severe PGD.
Between January 2007 and December 2015, 597 patients received a heart transplant at our center. Of those, severe PGD developed in 44 patients (7.4%), and they received a continuous-flow external VAD (n = 17) or VA-ECMO (n = 27) support within 24 hours after transplant. We compared early and late outcomes between groups.
Baseline characteristics were similar between groups. Implantation of the temporary VAD required longer cardiopulmonary bypass time compared with VA-ECMO (323 ± 86 minutes vs 216 ± 65 minutes, p < 0.0001). Patients who received a VAD were more likely to have longer support time (14 ± 17 days vs 5.2 ± 3.9 days, p = 0.011), a higher incidence of major bleeding requiring chest reexploration (77% vs 30%, p = 0.0047), and a higher incidence of renal failure requiring renal replacement therapy (53% vs 11%, p = 0.0045) after surgery. Overall hospital mortality was 27%. In-hospital mortality for VAD and VA-ECMO patients were 41% and 19%, respectively (p = 0.16). Ten patients (59%) were weaned from VAD support, and 24 (89%) were weaned from VA-ECMO support after adequate graft function recovery (p = 0.03). The 3-year post-transplant survival was 41% in the VAD group and 66% in the VA-ECMO group (p = 0.13).
For severe PGD, support with VA-ECMO appears to result in better clinical outcomes compared with VAD.
原发性移植心脏功能障碍（PGD）是原位心脏移植术后早期死亡的最常见原因之一。严重形式的PGD需要机械循环支持装置。静脉 - 动脉体外膜肺氧合（VA - ECMO）和临时心室辅助装置（VAD）支持均已被报道对严重PGD有用。
2007年1月至2015年12月期间，597例患者在我们中心接受了心脏移植。其中，44例患者（7.4%）发生了严重PGD，他们在移植后24小时内接受了连续流体外VAD（n = 17）或VA - ECMO（n = 27）支持。我们比较了两组的早期和晚期结果。
两组之间的基线特征相似。与VA - ECMO相比，植入临时VAD需要更长的体外循环时间（323±86分钟对216±65分钟，p < 0.0001）。接受VAD的患者更有可能有更长的支持时间（14±17天对5.2±3.9天，p = 0.011），术后需要再次开胸探查的大出血发生率更高（77%对30%，p = 0.0047），以及需要肾脏替代治疗的肾衰竭发生率更高（53%对11%，p = 0.0045）。总体医院死亡率为27%。VAD和VA - ECMO患者的住院死亡率分别为41%和19%（p = 0.16）。10例患者（59%）在VAD支持下撤机，24例（89%）在移植心脏功能充分恢复后从VA - ECMO支持下撤机（p = 0.03）。VAD组移植后3年生存率为41%，VA - ECMO组为66%（p = 0.13）。
对于严重PGD，与VAD相比，VA - ECMO支持似乎能带来更好的临床结果。
