Mullan Clancy W, Chouairi Fouad, Sen Sounok, Mori Makoto, Clark Katherine A A, Reinhardt Samuel W, Miller P Elliott, Fuery Michael A, Jacoby Daniel, Maulion Christopher, Anwer Muhammad, Geirsson Arnar, Mulligan David, Formica Richard, Rogers Joseph G, Desai Nihar R, Ahmad Tariq
Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA.
Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
JACC Heart Fail. 2021 Jun;9(6):420-429. doi: 10.1016/j.jchf.2021.01.010. Epub 2021 Mar 10.
The goal of this study was to describe outcomes of patients with bridge to heart transplantation (BTT) after changes were made to the donor heart allocation system.
Left ventricular assist devices (LVADs) have been used as a BTT. On October 18, 2018, the donor heart allocation system in the United States was updated.
This study identified adults in the United Network for Organ Sharing database with durable, continuous-flow LVAD at listing or implanted while listed between April 2017 and April 2020. Baseline recipient and donor characteristics, waitlist survival, and post-transplantation outcomes were compared pre- and post-allocation system change.
A total of 1,794 patients met inclusion criteria: 983 in the pre-change period and 814 afterward. The number of patients listed with LVAD decreased nationally over time from 102 in April 2017 to 12 in April 2020 (p < 0.001). The proportion of patients with LVAD at time of transplant decreased from 47% to 14%. Before the change, the majority were Status 1A (75.8%) at transplantation; afterward, most were Status 2/3 (67.8%). Transplantation rates were not different (85.4% vs. 83.6%; p = 0.225), but waitlist time decreased in the post period (82 vs. 65 days; p = 0.004). Donors were more likely to be high risk (39.0% vs. 32.2%; p = 0.005), and both ischemic times and distance traveled increased (3.4 h vs. 3.1 h; p < 0.001; 199 miles vs. 82 miles; p < 0.001). Waitlist survival did not change, but post-transplantation survival was worse in patients with BTT post-change (p < 0.001).
The number of patients with BTT on the transplant list decreased steadily and dramatically after the allocation system change. Although time to transplant decreased, there was an increase in post-transplant mortality. These data suggest that the risks and benefits of LVAD implantation as a BTT have changed under the new allocation system and that the appropriate indication for this treatment strategy warrants a re-evaluation.
本研究的目的是描述在供体心脏分配系统发生变化后，心脏移植过渡患者（BTT）的治疗结果。
左心室辅助装置（LVAD）已被用作心脏移植过渡手段。2018年10月18日，美国的供体心脏分配系统进行了更新。
本研究在器官共享联合网络数据库中识别出2017年4月至2020年4月期间在列入名单时或列入名单期间植入耐用、连续血流LVAD的成年人。比较了分配系统改变前后的基线受者和供体特征、等待名单生存率和移植后结果。
共有1794例患者符合纳入标准：改变前时期983例，之后814例。随着时间的推移，全国范围内列入LVAD名单的患者数量从2017年4月的102例下降到2020年4月的12例（p<0.001）。移植时使用LVAD的患者比例从47%降至14%。改变前，大多数患者在移植时为1A状态（75.8%）；之后，大多数为2/3状态（67.8%）。移植率没有差异（85.4%对83.6%；p=0.225），但等待名单时间在改变后减少（82天对65天；p=0.004）。供体更可能为高风险（39.0%对32.2%；p=0.005），缺血时间和运输距离均增加（3.4小时对3.1小时；p<0.001；199英里对82英里；p<0.001）。等待名单生存率没有变化，但改变后BTT患者的移植后生存率更差（p<0.001）。
分配系统改变后，移植名单上的BTT患者数量稳步且显著下降。尽管移植时间缩短，但移植后死亡率有所增加。这些数据表明，在新的分配系统下，作为BTT植入LVAD的风险和益处已经改变，并且这种治疗策略的合适适应症值得重新评估。
