The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.
Ann Thorac Surg. 2022 Oct;114(4):1453-1459. doi: 10.1016/j.athoracsur.2021.08.082. Epub 2021 Oct 21.
Digoxin has been associated with reduced interstage mortality for patients with functional single ventricles with aortic hypoplasia or ductal-dependent systemic circulation. The NEONATE (type of stage 1 palliation operation, postoperative extracorporeal membrane oxygenation, discharge with opiates, no digoxin at discharge, postoperative arch obstruction, moderate to severe tricuspid regurgitation without an oxygen requirement, and extra oxygen required at discharge in patients with moderate to severe tricuspid regurgitation) score can stratify patients by risk of death or transplantation (DTx) on the basis of clinical factors. The study investigators suspected a variable transplant-free survival benefit of digoxin in high-risk vs low-risk patients.
National Pediatric Cardiology Quality Improvement Collaborative patients discharged after stage 1 palliation with complete data were categorized as high- or low-risk on the basis of a modified NEONATE score. The primary outcome of DTx was evaluated. A mixed-effect regression evaluated associations between digoxin prescription and risk factors.
A total of 1199 patients were included; 399 (33%) were high risk. Baseline demographics were similar between the cohorts. Blalock-Taussig shunt or a hybrid operation, postoperative extracorporeal membrane oxygenation, opiate prescription, and significant tricuspid regurgitation or arch obstruction were more common in high-risk patients. The odds of DTx were 65% lower in high-risk patients prescribed digoxin compared with patients who were not (P = .001). Digoxin prescription was associated with 60.8% lower DTx in the high-risk cohort (7.8% vs 19.9%; P = .001). There was no significant difference in the DTx rate according to digoxin prescription in the low-risk cohort (4.7% vs 5.7%; P = .46). Blalock-Taussig shunt, aortic arch obstruction, and significant tricuspid regurgitation were most strongly associated with deriving a benefit from digoxin.
Digoxin use is associated with significant improvement in transplant-free survival in high-risk but not in low-risk interstage patients. A tailored approach to the use of digoxin in interstage patients may be warranted.
地高辛可降低主动脉发育不全或依赖导管循环的功能性单心室患者的中期死亡率。NEONATE（一期姑息手术的类型、术后体外膜氧合、阿片类药物出院、出院时无地高辛、术后弓部梗阻、中重度三尖瓣反流且无吸氧需求、中重度三尖瓣反流患者出院时需要额外吸氧）评分可根据临床因素对患者的死亡或移植（DTx）风险进行分层。研究人员怀疑在高危与低危患者中，地高辛的无移植生存获益存在差异。
根据改良的 NEONATE 评分，对接受一期姑息治疗后出院且资料完整的国家儿科心脏学质量改进协作组患者进行高风险或低风险分类。评估 DTx 的主要结果。混合效应回归评估地高辛处方与危险因素之间的关系。
共纳入 1199 例患者，其中 399 例（33%）为高风险。两组患者的基线人口统计学特征相似。高风险组更常见的是 Blalock-Taussig 分流术或杂交手术、术后体外膜氧合、阿片类药物处方以及严重的三尖瓣反流或弓部梗阻。与未接受地高辛治疗的患者相比，高风险患者接受地高辛治疗的 DTx 几率降低 65%（P<.001）。在高风险组中，地高辛治疗与 DTx 降低 60.8%相关（7.8%比 19.9%；P<.001）。低风险组中，地高辛处方与 DTx 发生率无显著差异（4.7%比 5.7%；P=.46）。Blalock-Taussig 分流术、主动脉弓部梗阻和严重三尖瓣反流与地高辛获益最相关。
地高辛的使用与高危中期患者的无移植生存显著改善相关，但与低危中期患者无关。对中期患者地高辛的使用可能需要采取个体化的方法。
