Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pa.
J Thorac Cardiovasc Surg. 2023 Aug;166(2):583-594.e3. doi: 10.1016/j.jtcvs.2021.09.061. Epub 2021 Oct 30.
This study aims to investigate the trends, outcomes, and risk factors for mortality after redo orthotopic heart transplantation.
The United Network for Organ Sharing registry was used to identify adult orthotopic heart transplantation recipients from 2000 to 2020 and stratify into primary and redo cohorts. Five-year post-transplant survival was compared between 2 propensity-matched cohorts. Multivariable modeling was performed to identify risk-adjusted predictors of redo post-transplant mortality, both conditional and nonconditional on shorter-term survival.
A total of 40,711 recipients were analyzed, 39,657 (97.4%) primary and 1054 (2.6%) redo. Redo recipients had a lower median age and were more frequently bridged with intravenous inotropes, intra-aortic balloon pump, or extracorporeal membrane oxygenation (all P < .05). One- and 5-year survivals were lower after redo orthotopic heart transplantation (90.0% vs 83.4% and 77.6% vs 68.6%, respectively) and remained lower after comparing 2 propensity-matched cohorts. Multivariable modeling found factors such as increasing donor age and graft ischemic times, along with pretransplant mechanical ventilation and blood transfusion, to negatively affect 90-day survival. Contingent on 1-year survival, donor factors such as hypertension (hazard ratio, 1.51; 95% confidence interval, 1.15-2.00, P = .004) and left ventricular ejection fraction less than 50% (hazard ratio, 2.22, 95% confidence interval, 1.16-4.24, P = .016) negatively affected survival at 5 years.
Although infrequently performed, redo orthotopic heart transplantation remains associated with worse post-transplant outcomes compared with primary orthotopic heart transplantation. Although several high-risk features were identified to affect post-retransplant outcomes in the acute perioperative period, donor characteristics such as hypertension and decreased ejection fraction continue to have lasting negative impacts in the longer term.
本研究旨在探讨再次原位心脏移植后死亡率的趋势、结果和危险因素。
利用美国器官共享网络登记处，从 2000 年至 2020 年确定成人原位心脏移植受者，并分为初次和再次两组。比较 2 个倾向评分匹配队列的 5 年移植后生存率。进行多变量建模，以确定再次移植后死亡率的风险调整预测因素，包括在短期生存条件下和非条件下的预测因素。
共分析了 40711 例受者，其中 39657 例（97.4%）为初次组，1054 例（2.6%）为再次组。再次组受者的中位年龄较低，更常接受静脉内正性肌力药、主动脉内球囊泵或体外膜肺氧合治疗（均 P < 0.05）。再次原位心脏移植后 1 年和 5 年的生存率较低（分别为 90.0%比 83.4%和 77.6%比 68.6%），在比较 2 个倾向评分匹配队列后，生存率仍然较低。多变量建模发现，供体年龄和移植物缺血时间的增加，以及移植前机械通气和输血等因素，对 90 天生存率有负面影响。在 1 年生存率的基础上，供体因素如高血压（危险比，1.51；95%置信区间，1.15-2.00，P = 0.004）和左心室射血分数低于 50%（危险比，2.22，95%置信区间，1.16-4.24，P = 0.016）对 5 年时的生存也有负面影响。
尽管再次原位心脏移植的实施频率较低，但与初次原位心脏移植相比，其移植后结局仍较差。虽然在围手术期的急性期确定了几个高危特征会影响再次移植后的结局，但供体特征，如高血压和射血分数降低，在长期内仍有持续的负面影响。
