Steffen Robert J, Blackstone Eugene H, Smedira Nicholas G, Soltesz Edward G, Hoercher Katherine J, Thuita Lucy, Starling Randall C, Mountis Maria, Moazami Nader
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
Ann Thorac Surg. 2017 Nov;104(5):1569-1576. doi: 10.1016/j.athoracsur.2017.03.066. Epub 2017 Jun 24.
Optimal timing of heart transplantation in patients supported with second-generation left ventricular assist devices (LVADs) is unknown. Despite this, patients with LVADs continue to receive priority on the heart transplant waiting list. Our objective was to determine the optimal timing of transplantation for patients bridged with continuous-flow LVADs.
A total of 301 HeartMate II LVADs (Thoratec Corp, Pleasanton, CA) were implanted in 285 patients from October 2004 to June 2013, and 86 patients underwent transplantation through the end of follow-up. Optimal transplantation timing was the product of surviving on LVAD support and surviving transplant.
Three-year survival after both HeartMate II implantation and heart transplantation was unchanged when transplantation occurred within 9 months of implantation. Survival decreased as the duration of support exceeded this. Preoperative risk factors for death on HeartMate II support were prior valve operation, prior coronary artery bypass grafting, low albumin, low glomerular filtration rate, higher mean arterial pressure, hypertension, and earlier date of implant. Survival for patients without these risk factors was lowest when transplant was performed within 3 months but was relatively constant with increased duration of support. Longer duration of support was associated with poorer survival for patients with many of these risk factors. Device reimplantation, intracranial hemorrhage, and postimplant dialysis during HeartMate II support were associated with decreased survival.
Survival of patients supported by the HeartMate II is affected by preoperative comorbidities and postoperative complications. Transplantation before complications is imperative in optimizing survival.
在接受第二代左心室辅助装置（LVAD）支持的患者中，心脏移植的最佳时机尚不清楚。尽管如此，LVAD患者在心脏移植等待名单上仍继续享有优先权。我们的目标是确定接受持续血流LVAD桥接的患者的最佳移植时机。
2004年10月至2013年6月，共285例患者植入了301台HeartMate II LVAD（Thoratec公司，普莱森顿，加利福尼亚州），86例患者在随访结束前接受了移植。最佳移植时机是LVAD支持下存活和移植后存活的乘积。
当移植在植入后9个月内进行时，HeartMate II植入和心脏移植后的三年生存率没有变化。随着支持时间超过这一期限，生存率下降。在HeartMate II支持下死亡的术前危险因素包括既往瓣膜手术、既往冠状动脉旁路移植术、低白蛋白、低肾小球滤过率、较高的平均动脉压、高血压和较早的植入日期。没有这些危险因素的患者，在3个月内进行移植时生存率最低，但随着支持时间的延长相对稳定。对于有许多这些危险因素的患者，支持时间越长，生存率越低。在HeartMate II支持期间进行装置再植入、颅内出血和植入后透析与生存率降低有关。
HeartMate II支持的患者的生存受术前合并症和术后并发症影响。在并发症出现之前进行移植对于优化生存至关重要。
