Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
J Heart Lung Transplant. 2022 Dec;41(12):1839-1849. doi: 10.1016/j.healun.2022.08.013. Epub 2022 Aug 31.
We sought to describe trends in extracorporeal membrane oxygenation (ECMO) use, and define the impact on PGD incidence and early mortality in lung transplantation.
Patients were enrolled from August 2011 to June 2018 at 10 transplant centers in the multi-center Lung Transplant Outcomes Group prospective cohort study. PGD was defined as Grade 3 at 48 or 72 hours, based on the 2016 PGD ISHLT guidelines. Logistic regression and survival models were used to contrast between group effects for event (i.e., PGD and Death) and time-to-event (i.e., death, extubation, discharge) outcomes respectively. Both modeling frameworks accommodate the inclusion of potential confounders.
A total of 1,528 subjects were enrolled with a 25.7% incidence of PGD. Annual PGD incidence (14.3%-38.2%, p = .0002), median LAS (38.0-47.7 p = .009) and the use of ECMO salvage for PGD (5.7%-20.9%, p = .007) increased over the course of the study. PGD was associated with increased 1 year mortality (OR 1.7 [95% C.I. 1.2, 2.3], p = .0001). Bridging strategies were not associated with increased mortality compared to non-bridged patients (p = .66); however, salvage ECMO for PGD was significantly associated with increased mortality (OR 1.9 [1.3, 2.7], p = .0007). Restricted mean survival time comparison at 1-year demonstrated 84.1 days lost in venoarterial salvaged recipients with PGD when compared to those without PGD (ratio 1.3 [1.1, 1.5]) and 27.2 days for venovenous with PGD (ratio 1.1 [1.0, 1.4]).
PGD incidence continues to rise in modern transplant practice paralleled by significant increases in recipient severity of illness. Bridging strategies have increased but did not affect PGD incidence or mortality. PGD remains highly associated with mortality and is increasingly treated with salvage ECMO.
本研究旨在描述体外膜肺氧合（ECMO）的使用趋势，并确定其对肺移植后肺移植后移植物功能障碍（PGD）发生率和早期死亡率的影响。
该研究纳入了 2011 年 8 月至 2018 年 6 月间 10 个移植中心的多中心肺移植结局组前瞻性队列研究中的患者。PGD 按照 2016 年 PGD-ISHLT 指南定义为 48 或 72 小时时的 3 级。采用逻辑回归和生存模型分别对比事件（即 PGD 和死亡）和时间事件（即死亡、拔管、出院）结局的组间效应。两种建模框架都可以包含潜在的混杂因素。
共纳入 1528 例患者，PGD 发生率为 25.7%。PGD 的年发生率（14.3%-38.2%，p=0.0002）、中位 LAS（38.0-47.7 p=0.009）和 ECMO 挽救性治疗 PGD（5.7%-20.9%，p=0.007）均呈逐年上升趋势。PGD 与 1 年死亡率增加相关（OR 1.7[95%CI 1.2, 2.3]，p=0.0001）。与非搭桥患者相比，搭桥策略与死亡率增加无关（p=0.66）；然而，PGD 的挽救性 ECMO 与死亡率显著相关（OR 1.9[1.3, 2.7]，p=0.0007）。1 年限制性平均生存时间比较显示，与无 PGD 患者相比，静脉动脉 ECMO 挽救治疗 PGD 的患者丧失 84.1 天（比值 1.3[1.1, 1.5]），静脉静脉 ECMO 挽救治疗 PGD 的患者丧失 27.2 天（比值 1.1[1.0, 1.4]）。
现代移植实践中 PGD 的发生率持续上升，同时患者病情严重程度也显著增加。搭桥策略有所增加，但并未影响 PGD 的发生率或死亡率。PGD 仍然与死亡率高度相关，并越来越多地采用挽救性 ECMO 治疗。
