Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts.
Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.
Ann Thorac Surg. 2020 Jan;109(1):218-224. doi: 10.1016/j.athoracsur.2019.07.013. Epub 2019 Aug 27.
The clinical response to postoperative complications after lung transplantation (LTx) may contribute to mortality differences among transplantation centers. The ability to avoid mortality after a complication-failure to rescue (FTR)-may be an effective quality metric in LTx.
The United Network for Organ Sharing database was queried for adult, first-time, lung-only transplantations from May 2005 to December 2015. Transplantation centers were stratified into equal-sized terciles on the basis of observed operative mortality rates. Several postoperative complications were identified, including stroke, acute rejection, acute kidney injury requiring hemodialysis, airway dehiscence, and extracorporeal membrane oxygenation 72 hours after surgery. Rates of FTR were calculated as the number of operative mortalities in patients who had complications divided by the number of patients who had any postoperative complications.
Our study population included 16,411 LTx operations performed at 69 transplantation centers. LTx centers were stratified into terciles with average perioperative mortality of 4.0% for low-mortality centers, 6.9% for intermediate-mortality centers, and 12.4% for high-mortality centers. Low-mortality centers had slightly lower complication rates (low, 15.0% vs intermediate, 17.1% vs high, 19.1%; P < .001). Differences in FTR rate were significantly more pronounced (low, 14.9% vs intermediate, 23.9% vs high, 34.2%; P < .001). Multivariable logistic regression and generalized linear models demonstrated an independent association between high FTR rates and high mortality in LTx (P < .001).
Differences in rates of FTR contribute significantly to per-center variability in mortality after LTx. FTR can serve as a quality metric to identify opportunities for improvement in management of perioperative adverse events.
肺移植（LTx）术后并发症的临床反应可能导致移植中心之间的死亡率差异。避免并发症-救援失败（FTR）后的死亡率可能是 LTx 中的一种有效的质量指标。
利用 2005 年 5 月至 2015 年 12 月期间的美国器官共享网络数据库，查询成人、首次、单肺移植。根据观察到的手术死亡率，将移植中心分为相等大小的三分之一。确定了几种术后并发症，包括中风、急性排斥反应、需要血液透析的急性肾损伤、气道裂开和手术后 72 小时的体外膜氧合。FTR 率的计算方法是并发症患者的手术死亡率除以有任何术后并发症的患者人数。
我们的研究人群包括 69 个移植中心进行的 16411 例 LTx 手术。将 LTx 中心分为三个三分之一，低死亡率中心的围手术期死亡率为 4.0%，中死亡率中心为 6.9%，高死亡率中心为 12.4%。低死亡率中心的并发症发生率略低（低，15.0%vs中，17.1%vs高，19.1%；P <.001）。FTR 率的差异更为明显（低，14.9%vs中，23.9%vs高，34.2%；P <.001）。多变量逻辑回归和广义线性模型表明，高 FTR 率与 LTx 中的高死亡率之间存在独立关联（P <.001）。
FTR 率的差异对 LTx 后死亡率的中心间变异性有显著影响。FTR 可以作为一种质量指标，以确定改善围手术期不良事件管理的机会。
