美国等待心脏移植的儿童的临时循环支持。
Temporary Circulatory Support in U.S. Children Awaiting Heart Transplantation.
机构信息
Division of Pediatrics Cardiology, Stanford University, the Lucile Packard Children's Hospital, Palo Alto, California; Heart Center and Heart Center Clinical and Translational Research Program, the Lucile Packard Children's Hospital, Palo Alto, California.
Department of Cardiac Surgery, Stanford University, the Lucile Packard Children's Hospital, Palo Alto, California; Heart Center and Heart Center Clinical and Translational Research Program, the Lucile Packard Children's Hospital, Palo Alto, California.
出版信息
J Am Coll Cardiol. 2017 Oct 31;70(18):2250-2260. doi: 10.1016/j.jacc.2017.08.072.
BACKGROUND
Extracorporeal membrane oxygenation (ECMO) has long served as the standard of care for short-term mechanical circulatory support in pediatrics. It is unknown whether newer-generation temporary circulatory support (TCS) devices afford children a meaningful survival advantage over ECMO.
OBJECTIVES
This study sought to determine whether bridge-to-heart transplant survival with a TCS device is superior to ECMO after adjusting for patient differences.
METHODS
All children ≤21 years of age listed for heart transplant from 2011 to 2015 who received a TCS device or ECMO as a bridge to transplant were identified using Organ Procurement and Transplantation Network data. Children supported with a TCS device were compared with a propensity score (PS)-matched cohort of children supported with ECMO as a bridge to transplant. The primary endpoint was Kaplan-Meier survival to transplant.
RESULTS
The number of TCS devices implanted in children increased from ≤3 per year before 2011 to 50 in 2015. Overall, 93 patients implanted with TCS devices were included for analysis (59% left ventricular assist devices, 23% right ventricular assist devices, 18% biventricular assist devices). The most commonly used device was the CentriMag-PediMag system (65%), followed by TandemHeart (18%), Rotaflow (6%), and Impella (5%). Among 164 PS-matched patients, support duration was longer for the TCS cohort (median 19 days vs. 6 days; p < 0.001), and was longest for the CentriMag-PediMag (24 days vs. 6 days; p < 0.001) with 27% supported for >60 days. Compared with the ECMO cohort, the PS-matched TCS cohort had longer survival to transplant (hazard ratio: 0.49; 95% confidence interval: 0.30 to 0.79) and longer overall survival (hazard ratio: 0.61; 95% confidence interval: 0.39 to 0.96), with 90-day mortality before transplant that was modestly reduced (from 45% with ECMO to 39% with TCS).
CONCLUSIONS
The use of TCS devices in children as a bridge to transplant has risen rapidly in recent years, led by the growth of magnetically levitated centrifugal flow pumps. Compared with conventional ECMO, TCS durations are longer, and more importantly, patient survival is superior.
背景
体外膜肺氧合（ECMO）长期以来一直是儿科短期机械循环支持的标准治疗方法。目前尚不清楚新一代临时循环支持（TCS）设备是否能为儿童提供比 ECMO 更有意义的生存优势。
目的
本研究旨在确定在调整患者差异后，使用 TCS 设备进行桥接心脏移植的存活率是否优于 ECMO。
方法
使用器官获取和移植网络（Organ Procurement and Transplantation Network）的数据，确定了 2011 年至 2015 年期间接受 TCS 设备或 ECMO 作为桥接移植的所有≤21 岁的心脏移植患儿。将使用 TCS 设备的患儿与使用 ECMO 作为桥接移植的倾向评分（PS）匹配队列的患儿进行比较。主要终点是 Kaplan-Meier 移植生存率。
结果
在 2011 年前，每年植入 TCS 设备的数量≤3 台，到 2015 年增加到 50 台。总的来说，纳入了 93 名接受 TCS 设备治疗的患儿进行分析（59%为左心室辅助设备，23%为右心室辅助设备，18%为双心室辅助设备）。最常用的设备是 CentriMag-PediMag 系统（65%），其次是 TandemHeart（18%）、Rotaflow（6%）和 Impella（5%）。在 164 名 PS 匹配的患者中，TCS 组的支持时间更长（中位数 19 天 vs. 6 天；p<0.001），CentriMag-PediMag 的支持时间最长（24 天 vs. 6 天；p<0.001），27%的患者支持时间超过 60 天。与 ECMO 组相比，PS 匹配的 TCS 组移植后生存率更高（风险比：0.49；95%置信区间：0.30 至 0.79），总生存率更高（风险比：0.61；95%置信区间：0.39 至 0.96），移植前 90 天死亡率略有降低（从 ECMO 的 45%降至 TCS 的 39%）。
结论
近年来，使用 TCS 设备作为桥接移植治疗儿童的应用迅速增加，主要是由于磁悬浮离心泵的发展。与传统 ECMO 相比，TCS 的持续时间更长，更重要的是，患者的生存率更高。
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