再次开胸行心脏移植术后早期死亡率增加。

Reoperative sternotomy is associated with increased early mortality after cardiac transplantation.

机构信息

Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA.

Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA.

出版信息

Eur J Cardiothorac Surg. 2019 Jun 1;55(6):1136-1143. doi: 10.1093/ejcts/ezy443.

DOI:10.1093/ejcts/ezy443

PMID:30649307

Abstract

OBJECTIVES

Outcomes of cardiac transplantation in patients undergoing reoperative sternotomy are often worse than primary transplants. However, the risks imposed by a prior sternotomy, left ventricular assist device (LVAD) or retransplantation have not been independently analysed.

METHODS

Using the United Network for Organ Sharing (UNOS) database, a retrospective propensity-matched cohort analysis was performed on 14 730 patients who received a heart transplant between 2005 and 2017. Of 7365 patients who underwent a reoperative sternotomy, 4526 (61%) patients had previous cardiac surgery, 2364 (32%) patients had an LVAD and 475 (6%) patients had a previous transplant. Baseline characteristics were compared, and survival was analysed using a Cox model.

RESULTS

Compared to patients who underwent a primary transplant, patients with a prior sternotomy had a worse long-term survival (P < 0.001). There was no significant difference in survival between patients who had an LVAD and those who had a previous cardiac operation. However, all subgroups had better survival compared to patients who underwent a retransplant (P < 0.05). On the multivariable analysis, prior sternotomy and radiation demonstrated an increased risk of death compared to primary transplants [prior cardiac surgery: hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.05-1.22; P = 0.001; LVAD: HR 1.19, 95% CI 1.08-1.32; P = 0.001; retransplant: HR 1.68, 95% CI 1.42-1.99; P < 0.001; radiation: HR 1.82, 95% CI 1.00-3.30; P = 0.04]. When excluding patients who died in the first year, there were no significant differences in survival between the primary transplant, prior cardiac surgery, LVAD and retransplant groups.

CONCLUSIONS

Prior sternotomy is a risk factor for worse survival after cardiac transplantation, mainly due to increased early postoperative mortality. A history of prior transplant confers the greatest risk compared to those who received an LVAD or had prior cardiac surgery.

摘要

目的

在接受再次开胸心脏移植的患者中，其术后结局通常比初次移植患者差。然而，既往开胸史、左心室辅助装置（LVAD）或再次移植带来的风险尚未被单独分析。

方法

利用美国器官共享网络（UNOS）数据库，对 2005 年至 2017 年间接受心脏移植的 14730 例患者进行回顾性倾向评分匹配队列分析。在 7365 例行再次开胸的患者中，4526 例（61%）患者有既往心脏手术史，2364 例（32%）患者有 LVAD，475 例（6%）患者有既往移植史。比较了各组的基线特征，并采用 Cox 模型分析了生存率。

结果

与初次移植患者相比，既往开胸患者的长期生存率较差（P<0.001）。有 LVAD 和既往心脏手术史的患者之间的生存率无显著差异。然而，与再次移植患者相比，所有亚组的生存率均较好（P<0.05）。多变量分析显示，与初次移植相比，既往开胸和放疗增加了死亡风险[既往心脏手术：风险比（HR）1.13，95%置信区间（CI）1.05-1.22；P=0.001；LVAD：HR 1.19，95%CI 1.08-1.32；P=0.001；再次移植：HR 1.68，95%CI 1.42-1.99；P<0.001；放疗：HR 1.82，95%CI 1.00-3.30；P=0.04]。当排除移植后 1 年内死亡的患者后，初次移植、既往心脏手术、LVAD 和再次移植组之间的生存率无显著差异。