Division of Cardiothoracic Surgery, Department of Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY.
Department of Medicine, Stanford University Medical Center, Stanford, Calif.
J Thorac Cardiovasc Surg. 2019 Jul;158(1):171-181.e1. doi: 10.1016/j.jtcvs.2019.01.135. Epub 2019 Feb 28.
Outcomes have improved in patients bridged to heart transplant on contemporary continuous-flow ventricular assist devices over the past decade. We evaluated mechanical circulatory support as a means to bridge patients to cardiac retransplantation.
We retrospectively reviewed 464 patients who underwent cardiac retransplant from the United Network for Organ Sharing database between January 2006 and November 2016. Pre- and post-transplant data were compared between patients bridged to retransplant with mechanical circulatory support (n = 81) and those without mechanical circulatory support (n = 383).
The mean ages for the patients in the mechanical circulatory support and nonmechanical circulatory support cohorts were 41.2 ± 16 years and 42.1 ± 15.7 years, respectively (P = .64). Patients bridged with mechanical circulatory support were placed on extracorporeal membrane oxygenation (n = 29, 35.8%), a total artificial heart (n = 13, 16.0%), or a temporary or durable ventricular assist device (n = 39, 48.1%). Twelve patients (14.8%) were placed on a second device before retransplant. Thirty-nine percent of the mechanical circulatory support group were indicated for listing because of primary graft dysfunction or acute rejection versus 6% of the nonmechanical circulatory support group (P < .01). Likewise, 30% of patients in the mechanical circulatory support group were listed for cardiac allograft vasculopathy compared with 59% of the nonmechanical circulatory support group (P < .01). Thirty-day mortality was significantly higher in the mechanical circulatory support group (17.8% vs 4.8%, P < .01). However, patients who were bridged with a ventricular assist device or total artificial heart had comparable midterm outcomes to the nonmechanical circulatory support group.
Patients who require mechanical circulatory support bridge to retransplantation belong to a high-risk cohort. Comparable midterm outcomes to the nonmechanical circulatory support cohort were demonstrated when patients' conditions allow for bridge with a ventricular assist device or total artificial heart. Bridging to retransplantation with extracorporeal membrane oxygenation remains a relative contraindication.
在过去十年中，使用当代连续流动心室辅助装置桥接进行心脏移植的患者的预后得到了改善。我们评估了机械循环支持作为桥接患者进行心脏再移植的手段。
我们回顾性分析了 2006 年 1 月至 2016 年 11 月期间，器官共享联合网络数据库中接受心脏再移植的 464 例患者。比较了机械循环支持桥接（n=81）与无机械循环支持桥接（n=383）患者的术前和术后数据。
机械循环支持组和非机械循环支持组患者的平均年龄分别为 41.2±16 岁和 42.1±15.7 岁（P=0.64）。接受机械循环支持的患者接受了体外膜肺氧合（n=29，35.8%）、全人工心脏（n=13，16.0%）或临时或永久性心室辅助装置（n=39，48.1%）。12 例（14.8%）患者在再移植前接受了第二种装置。39%的机械循环支持组因原发性移植物功能障碍或急性排斥而被列为移植适应证，而非机械循环支持组为 6%（P<.01）。同样，机械循环支持组中有 30%的患者因心脏同种异体移植血管病而被列为移植适应证，而非机械循环支持组为 59%（P<.01）。机械循环支持组的 30 天死亡率显著更高（17.8%比 4.8%，P<.01）。然而，接受心室辅助装置或全人工心脏桥接的患者与非机械循环支持组的中期结果相当。
需要机械循环支持桥接进行再移植的患者属于高危人群。当患者情况允许使用心室辅助装置或全人工心脏桥接时，与非机械循环支持组具有相当的中期结果。使用体外膜肺氧合桥接进行再移植仍然是相对禁忌证。
