种族差异存在于儿童心室辅助装置支持的利用和移植后生存获益中。
Racial disparity exists in the utilization and post-transplant survival benefit of ventricular assist device support in children.
机构信息
The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Division of Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, Arizona.
出版信息
J Heart Lung Transplant. 2023 May;42(5):585-592. doi: 10.1016/j.healun.2022.12.020. Epub 2022 Dec 28.
PURPOSE
Children of minority race and ethnicity experience inferior outcomes postheart transplantation (HTx). Studies have associated ventricular assist device (VAD) bridge-to-transplant (BTT) with similar-to-superior post-transplant-survival (PTS) compared to no mechanical circulatory support. It is unclear whether racial and ethnic discrepancies exist in VAD utilization and outcomes.
METHODS
The United Network for Organ Sharing (UNOS) database was used to identify 6,121 children (<18 years) listed for HTx between 2006 and 2021: black (B-22% of cohort), Hispanic (H-21%), and white (W-57%). VAD utilization, outcomes, and PTS were compared between race/ethnicity groups. Multivariable Cox proportional analyses were used to study the association of race and ethnicity on PTS with VAD BTT, using backward selection for covariates.
RESULTS
Black children were most ill at listing, with greater proportions of UNOS status 1A/1 (p < 0.001 vs H & W), severe functional limitation (p < 0.001 vs H & W), and greater inotrope requirements (p < 0.05 vs H). Non-white children had higher proportions of public insurance. VAD utilization at listing was: B-11%, H-8%, W-8% (p = 0.001 for B vs H & W). VAD at transplant was: B-24%, H-21%, W-19% (p = 0.001 for B vs H). At transplant, all VAD patients had comparable clinical status (functional limitation, renal/hepatic dysfunction, inotropes, mechanical ventilation; all p > 0.05 between groups). Following VAD, hospital outcomes and one-year PTS were equivalent but long-term PTS was significantly worse among non-whites-(p < 0.01 for W vs B & H). On multivariable analysis, black race independently predicted mortality (hazard ratio 1.67 [95% confidence interval 1.22-2.28]) while white race was protective (0.54 [0.40-0.74]).
CONCLUSIONS
Pediatric VAD use is, seemingly, equitable; the most ill patients receive the most VADs. Despite similar pretransplant and early post-transplant benefits, non-white children experience inferior overall PTS after VAD BTT.
目的
少数族裔儿童在心脏移植（HTx）后预后较差。研究表明，心室辅助装置（VAD）桥接移植（BTT）与无机械循环支持相比，具有相似甚至更好的移植后生存（PTS）。目前尚不清楚在 VAD 的使用和结果方面是否存在种族和民族差异。
方法
使用美国器官共享网络（UNOS）数据库，确定 2006 年至 2021 年间接受 HTx 的 6121 名儿童（<18 岁）：黑人（B-22%的队列）、西班牙裔（H-21%）和白人（W-57%）。比较种族/民族群体之间的 VAD 使用情况、结果和 PTS。使用多变量 Cox 比例分析，使用向后选择协变量来研究种族和民族对 PTS 的影响与 VAD BTT 的关系。
结果
黑人患儿在入院时病情最严重，UNOS 状态 1A/1 的比例较高（p<0.001 与 H 和 W），严重功能受限（p<0.001 与 H 和 W），以及更高的儿茶酚胺需求（p<0.05 与 H）。非白人儿童拥有更高比例的公共保险。入院时 VAD 使用情况为：B-11%，H-8%，W-8%（p=0.001 与 H 和 W 相比）。移植时的 VAD 为：B-24%，H-21%，W-19%（p=0.001 与 B 相比）。在移植时，所有 VAD 患者的临床状况相似（功能受限、肾功能/肝功能障碍、儿茶酚胺、机械通气；所有组间差异均无统计学意义（p>0.05））。在 VAD 之后，住院结局和一年 PTS 是相等的，但非白人的长期 PTS 明显较差（p<0.01 与 W 相比）。多变量分析表明，黑人种族独立预测死亡率（危险比 1.67[95%置信区间 1.22-2.28]），而白人种族则具有保护作用（0.54[0.40-0.74]）。
结论
儿科 VAD 的使用似乎是公平的；最严重的患者接受了最多的 VAD。尽管有类似的移植前和早期移植后获益，但非白人儿童在接受 VAD BTT 后总体 PTS 较差。
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