Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA.
Department of Biostatistics, Virginia Commonwealth University, Richmond, VA.
J Cardiothorac Vasc Anesth. 2020 Feb;34(2):392-400. doi: 10.1053/j.jvca.2019.10.003. Epub 2019 Oct 10.
An increasing number of patients undergoing heart transplantation are being bridged with left ventricular assist devices (LVADs). Bridge-to-transplantation (BTT) LVAD has improved wait list survival remarkably. Historically, post-heart transplantation survival in BTT-LVAD patients, however, has remained inferior to that of primary heart transplantation. The authors hypothesized that in the modern era, the difference between post-heart transplantation survival in BTT-LVAD versus primary heart transplantation should be reduced. The objective of the present study was to determine whether there has been a change in survival after heart transplantation in patients with prior LVAD. The present study's cohort was compared with a historical cohort using the United Network of Organ Sharing (UNOS) database from 1995 to 2004. DESIGN: Retrospective observational analysis of data from the United Network of Organ Sharing database.
Registry-based, observational, retrospective.
Patients undergoing adult orthotopic heart transplantation, excluding redo transplantation and multiorgan transplantations.
None.
From the UNOS database, 22,065 patients who underwent heart transplantation between January 1, 2006, and December 31, 2016, were analyzed. Of these, 7,008 (31.76%) patients had prior LVAD (BTT-LVAD). Data analysis was performed with R software (Version 3.5.1) for Kaplan-Meier survival analysis and Cox proportional hazard ratio (HR) modeling to identify variables influencing survival. For patients with prior LVAD, the overall HR was 1.15 (95% confidence interval [CI] 1.07-1.24) for survival. An HR of 3.22 (95% CI 2.23-4.68) for death in patients who received extracorporeal membrane oxygenation post-transplantation and an HR of 0.72 (95% CI 0.58-0.90) for survival in patients whose procedures were performed in high-volume centers performing more than 35 transplantations per year were identified.
Reduced survival in patients who received an LVAD before heart transplantation persists. However, there may have been a slight improvement in the HR for survival in the study cohort in the recent decade compared with the historical cohort from previous decades. It is intriguing that despite the paramount advances in both technology and clinical practice of LVAD, relatively minor survival benefit, if any, has occurred in post-heart transplantation for patients bridged with prior LVAD.
越来越多接受心脏移植的患者采用左心室辅助装置（LVAD）桥接。桥接移植（BTT）LVAD 显著提高了移植等待名单上的存活率。然而，历史上，BTT-LVAD 患者心脏移植后的存活率仍低于初次心脏移植。作者假设，在现代，BTT-LVAD 与初次心脏移植后患者的存活率差异应有所缩小。本研究的目的是确定在接受 LVAD 桥接治疗的患者中，心脏移植后的生存率是否发生了变化。本研究队列与使用 1995 年至 2004 年美国器官共享网络（UNOS）数据库的历史队列进行了比较。
对 UNOS 数据库中的数据进行回顾性观察性分析。
基于注册的观察性回顾性研究。
接受成人原位心脏移植的患者，不包括再次移植和多器官移植。
无。
从 UNOS 数据库中分析了 2006 年 1 月 1 日至 2016 年 12 月 31 日期间接受心脏移植的 22065 名患者。其中，7008 名（31.76%）患者有既往 LVAD（BTT-LVAD）病史。使用 R 软件（版本 3.5.1）进行 Kaplan-Meier 生存分析和 Cox 比例风险比（HR）建模，以确定影响生存的变量。对于有既往 LVAD 病史的患者，整体 HR 为 1.15（95%置信区间 [CI] 1.07-1.24）。移植后接受体外膜肺氧合（ECMO）的患者死亡的 HR 为 3.22（95%CI 2.23-4.68），而在每年进行超过 35 例移植的大容量中心进行手术的患者的 HR 为 0.72（95%CI 0.58-0.90）。
接受心脏移植前接受 LVAD 治疗的患者生存率降低。然而，与前几十年的历史队列相比，在最近十年的研究队列中，生存率的 HR 可能略有改善。有趣的是，尽管 LVAD 的技术和临床实践都取得了重大进展，但接受 BTT-LVAD 桥接治疗的患者在心脏移植后，生存率仅略有提高（如果有的话）。
