Moayedi Yasbanoo, Multani Ashrit, Bunce Paul E, Henricksen Erik, Lee Roy, Yang Wenjia, Gomez Carlos A, Garvert Donn W, Tremblay-Gravel Maxime, Duclos Sebastien, Hiesinger William, Ross Heather J, Khush Kiran K, Montoya Jose G, Teuteberg Jeffrey J
Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, CA, USA.
Ted Rogers Centre of Excellence in Heart Function, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
Clin Transplant. 2019 Oct;33(10):e13692. doi: 10.1111/ctr.13692. Epub 2019 Sep 17.
Despite significant advances in durable mechanical support survival, infectious complications remain the most common adverse event after ventricular assist device (VAD) implantation and the leading cause of early death after transplantation. In this study, we aim to describe our local infectious epidemiology and review short-term survival and infectious incidence rates in the post-transplantation period and assess risk factors for infectious episodes after transplantation.
Retrospective single-center study of all consecutive adult heart transplant patients from 2008 to 2017. Survival data were estimated and summarized using the Kaplan-Meier method. We quantified and evaluated the difference in the incidence rate between patients with and without infection using a Fine-Gray model. The outcome of interest is the time to first infection diagnosis with post-transplant death as the competing event.
Among 278 heart transplant patients, 74 (26.5%) underwent LVAD implantation. Twenty-one patients (28.3%) developed an infection while supported by an LVAD. When compared to patients supported by an LVAD without a preceding infection, BMI was significantly greater (31.2 vs 27.8 kg/m , P = .03). Median follow-up post-transplantation was 3.01 years. Significant risk factors for the competing risk regression for infection after heart transplantation include LVAD infection (HR 1.94, [95% CI] 1.11-3.39, P = .020) and recipient COPD (HR 2.14, [95% CI] 1.39-3.32, P = .001) when adjusted for recipient age, gender, hypertension, diabetes mellitus, and body mass index.
Patients with LVAD-related infection had a significantly increased risk of infectious complications after heart transplantation. Further research on the avoidance of induction agents and reduced maintenance immunosuppression in this patient population is warranted.
尽管在持久的机械支持生存方面取得了重大进展，但感染性并发症仍然是心室辅助装置（VAD）植入后最常见的不良事件，也是移植后早期死亡的主要原因。在本研究中，我们旨在描述我们当地的感染流行病学，回顾移植后短期生存和感染发生率，并评估移植后感染发作的危险因素。
对2008年至2017年所有连续的成年心脏移植患者进行回顾性单中心研究。生存数据采用Kaplan-Meier方法进行估计和总结。我们使用Fine-Gray模型量化并评估了感染患者与未感染患者之间发病率的差异。感兴趣的结局是首次感染诊断时间，以移植后死亡作为竞争事件。
在278例心脏移植患者中，74例（26.5%）接受了左心室辅助装置（LVAD）植入。21例患者（28.3%）在LVAD支持期间发生了感染。与未发生过感染的LVAD支持患者相比，体重指数（BMI）显著更高（31.2 vs 27.8kg/m²，P = 0.03）。移植后的中位随访时间为3.01年。心脏移植后感染竞争风险回归的显著危险因素包括LVAD感染（风险比[HR]1.94，[95%置信区间（CI）]1.11 - 3.39，P = 0.020）和受者慢性阻塞性肺疾病（COPD）（HR 2.14，[95%CI]1.39 - 3.32，P = 0.001），在对受者年龄、性别、高血压、糖尿病和体重指数进行调整后。
与LVAD相关感染的患者心脏移植后感染性并发症的风险显著增加。有必要对该患者群体避免使用诱导剂和减少维持性免疫抑制进行进一步研究。
