Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California.
Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California; Division of Cardiology, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, California.
Ann Thorac Surg. 2020 Dec;110(6):1997-2005. doi: 10.1016/j.athoracsur.2020.03.129. Epub 2020 May 23.
The objective of this study was to characterize practical use trends and outcomes for intraaortic balloon pump (IABP) and percutaneous left ventricular assist device (pVAD) use in cardiogenic shock at a national level.
An analysis of all adult patients admitted nonelectively for cardiogenic shock from January 2008 through December 2017 was performed using the National Inpatient Sample. Trends of inpatient IABP and pVAD use were analyzed using survey-weighted estimates and the modified Cochran-Armitage test for significance. Multivariable regression models and inverse probability of treatment weights were used to perform risk-adjusted analyses of pVAD mortality, a composite of adverse events (AE), and resource use, with IABP as reference.
Of an estimated 774,310 patients admitted with cardiogenic shock, 143,051 received a device: IABP, 127,792 (16.5%); or pVAD, 15,259 (2.0%). IABP use decreased (23.8% to 12.7%; P for trend <.001), whereas pVAD implantation increased significantly during the study period (0.2% to 4.5%; P for trend <.001). Inverse probability of treatment weights demonstrated significantly higher odds of mortality with pVAD (odds ratio, 1.9; 95% confidence interval, 1.7 to 2.2), but not AE (odds ratio, 1.1; 95% confidence interval, 0.96 to 1.27), compared with IABP. After risk adjustment, pVAD use was associated with an additional $15,202 (P < .001) in cost for survivors and $29,643 for nonsurvivors (P < .001).
Over the study period, the rate of pVAD use for cardiogenic shock significantly increased. Compared with IABP, pVAD use was associated with increased mortality, higher costs, and several AEs. Multi-institutional clinical trials with rigorous inclusion criteria are warranted to evaluate the clinical utility of pVADs in the modern era.
本研究旨在从全国层面上描述主动脉内球囊泵（IABP）和经皮左心室辅助装置（pVAD）在心源性休克治疗中的实际应用趋势和结果。
利用国家住院患者样本（National Inpatient Sample），对 2008 年 1 月至 2017 年 12 月期间非选择性入院的心源性休克成年患者进行分析。使用调查加权估计和修正 Cochran-Armitage 检验对 IABP 和 pVAD 的住院使用趋势进行分析。采用多变量回归模型和逆概率治疗权重（inverse probability of treatment weights）对 pVAD 死亡率、不良事件（AE）复合结局和资源利用进行风险调整分析，以 IABP 为参照。
在估计的 774310 例因心源性休克入院的患者中，有 143051 例接受了设备治疗：IABP 治疗 127792 例（16.5%）；或 pVAD 治疗 15259 例（2.0%）。在此研究期间，IABP 的使用率逐渐下降（23.8%至 12.7%；P<0.001），而 pVAD 的植入显著增加（0.2%至 4.5%；P<0.001）。经逆概率治疗权重校正后，pVAD 治疗的死亡率显著高于 IABP（比值比，1.9；95%置信区间，1.7 至 2.2），但 AE 发生率没有差异（比值比，1.1；95%置信区间，0.96 至 1.27）。风险调整后，pVAD 治疗的幸存者的成本增加了 15202 美元（P<0.001），而非幸存者的成本增加了 29643 美元（P<0.001）。
在此研究期间，pVAD 在心源性休克治疗中的使用率显著增加。与 IABP 相比，pVAD 的应用与死亡率升高、成本增加和多种 AE 相关。需要进行多机构的临床试验，严格纳入标准，以评估 pVAD 在现代时代的临床应用价值。
