From the Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.
ASAIO J. 2020 Mar;66(3):261-267. doi: 10.1097/MAT.0000000000001119.
For patients bridged to transplant (BTT) with left ventricular assist devices (LVAD), data regarding the use of induction immunosuppressive therapy remain limited. The objectives of the current study were to describe the current trends and clinical consequences of IT in patients BTT with LVAD. The United Network of Organ Sharing database was queried to identify adult, single-organ heart transplant recipients who were BTT with LVAD between 2008 and 2018. Propensity score matching was then used to balance clinical covariates between those patient who did and did not receive IT. The primary outcomes of interest were graft survival, hospitalization for rejection and infection, and freedom from transplant coronary artery disease (TCAD). In the overall cohort, 49.1% (n = 3,978) received IT, with basiliximab being the most commonly used agent followed by antithymocyte globulin. After propensity score matching, 4,388 patients (2,194 without induction and 2,194 with induction) were identified. Between those who did and did not receive IT, there was no significant difference in graft survival, freedom from hospitalization for rejection, and freedom from hospitalization for infection. Patients who received IT experienced increased freedom from TCAD (p = 0.004) with unadjusted hazard ratio of 0.81 (95% Cardiac Index: 0.70-0.93). For freedom from TCAD, antithymocyte globulin was associated with better outcomes than basiliximab (80.2% vs. 73.1% at 5 years, log rank p value = 0.004). In a sensitivity analysis, there was no significant increase in hospitalization for infection in those patients with an infected LVAD before transplant. Use of induction therapy in patients BTT with LVAD appears to be safe and feasible, without a significant increase in the risk of infection or rejection, even in those patients with pretransplant device-related infections. IT, particularly antithymocyte globulin, was associated with increased time to development of TCAD. Routine use of IT in patients BTT with LVAD may be considered, and further randomized control trials are warranted to further support these data.
对于接受左心室辅助装置（LVAD）桥接移植（BTT）的患者，关于诱导免疫抑制治疗的数据仍然有限。本研究的目的是描述目前 BTT 患者接受 LVAD 治疗时诱导免疫治疗的趋势和临床结果。使用美国器官共享网络数据库，确定了 2008 年至 2018 年期间接受 LVAD 桥接移植的成年单器官心脏移植受者。然后使用倾向评分匹配来平衡接受和不接受诱导免疫治疗的患者之间的临床协变量。主要研究结果是移植物存活率、排斥反应和感染住院率以及免于移植后冠状动脉疾病（TCAD）的发生。在总体队列中，49.1%（n=3978）接受了 IT，最常用的药物是巴利昔单抗，其次是抗胸腺细胞球蛋白。在进行倾向评分匹配后，确定了 4388 名患者（2194 名未接受诱导免疫治疗，2194 名接受诱导免疫治疗）。在接受和不接受 IT 的患者之间，移植物存活率、免于排斥反应住院率和免于感染住院率无显著差异。接受 IT 的患者免于 TCAD 的发生率更高（p=0.004），未经调整的风险比为 0.81（95%CI：0.70-0.93）。对于免于 TCAD，与巴利昔单抗相比，抗胸腺细胞球蛋白与更好的结果相关（5 年时分别为 80.2%和 73.1%，对数秩检验 p 值=0.004）。在敏感性分析中，在移植前 LVAD 发生感染的患者中，感染住院率没有显著增加。在接受 LVAD 桥接移植的患者中使用诱导治疗似乎是安全可行的，不会增加感染或排斥反应的风险，即使在移植前有与设备相关的感染的患者中也是如此。IT，特别是抗胸腺细胞球蛋白，与 TCAD 发生时间的增加相关。在接受 LVAD 桥接移植的患者中常规使用 IT 可能是可行的，还需要进一步的随机对照试验来进一步支持这些数据。
