Zakko Jason, Premkumar Akash, Logan April J, Sneddon Jeffrey M, Brock Guy N, Pawlik Timothy M, Mokadam Nahush A, Whitson Bryan A, Lampert Brent C, Washburn William K, Osho Asishana A, Ganapathi Asvin M, Schenk Austin D
Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
Harvard Medical School, Boston, Mass.
J Thorac Cardiovasc Surg. 2024 Mar;167(3):1077-1087.e13. doi: 10.1016/j.jtcvs.2023.02.019. Epub 2023 Feb 23.
Assessing heart transplant program quality using short-term survival is insufficient. We define and validate the composite metric textbook outcome and examine its association with overall survival.
We identified all primary, isolated adult heart transplants in the United Network for Organ Sharing/Organ Procurement and Transplantation Network Standard Transplant Analysis and Research files from May 1, 2005, to December 31, 2017. Textbook outcome was defined as length of stay 30 days or less; ejection fraction greater than 50% during 1-year follow-up; functional status 80% to 100% at 1 year; freedom from acute rejection, dialysis, and stroke during the index hospitalization; and freedom from graft failure, dialysis, rejection, retransplantation, and mortality during the first year post-transplant. Univariate and multivariate analyses were performed. Factors independently associated with textbook outcome were used to create a predictive nomogram. Conditional survival at 1 year was measured.
A total of 24,620 patients were identified with 11,169 (45.4%, 95% confidence interval, 44.7-46.0) experiencing textbook outcome. Patients with textbook outcome were more likely free from preoperative mechanical support (odds ratio, 3.504, 95% confidence interval, 2.766 to 4.439, P < .001), free from preoperative dialysis (odds ratio, 2.295, 95% confidence interval, 1.868-2.819, P < .001), to be not hospitalized (odds ratio, 1.264, 95% confidence interval, 1.183-1.349, P < .001), to be nondiabetic (odds ratio, 1.187, 95% confidence interval, 1.113-1.266, P < .001), and to be nonsmokers (odds ratio, 1.160, 95% confidence interval,1.097-1.228, P < .001). Patients with textbook outcome have improved long-term survival relative to patients without textbook outcome who survive at least 1 year (hazard ratio for death, 0.547, 95% confidence interval, 0.504-0.593, P < .001).
Textbook outcome is an alternative means of examining heart transplant outcomes and is associated with long-term survival. The use of textbook outcome as an adjunctive metric provides a holistic view of patient and center outcomes.
仅用短期生存率评估心脏移植项目质量是不够的。我们定义并验证了综合指标“教科书式结局”，并研究其与总体生存率的关联。
我们在器官共享联合网络/器官获取与移植网络标准移植分析与研究文件中，识别出2005年5月1日至2017年12月31日期间所有初次、孤立的成人心脏移植病例。“教科书式结局”定义为住院时间30天或更短；1年随访期间射血分数大于50%；1年时功能状态为80%至100%；在首次住院期间无急性排斥反应、透析和中风；在移植后第一年无移植物衰竭、透析、排斥反应、再次移植和死亡。进行了单因素和多因素分析。与“教科书式结局”独立相关的因素用于创建预测列线图。测量了1年时的条件生存率。
共识别出24,620例患者，其中11,169例（45.4%，95%置信区间，44.7 - 46.0）达到“教科书式结局”。达到“教科书式结局”的患者更有可能术前未接受机械支持（比值比，3.504，95%置信区间，2.766至4.439，P <.001），术前未接受透析（比值比，2.295，95%置信区间，1.868 - 2.819，P <.001），未住院（比值比，1.264，95%置信区间，1.183 - 1.349，P <.001），非糖尿病（比值比，1.187，95%置信区间，1.113 - 1.266，P <.001），且不吸烟（比值比，1.160，95%置信区间，1.097 - 1.228，P <.001）。与至少存活1年但未达到“教科书式结局”的患者相比，达到“教科书式结局”的患者长期生存率有所提高（死亡风险比，0.547，95%置信区间，0.504 - 0.593，P <.001）。
“教科书式结局”是评估心脏移植结局的一种替代方法，且与长期生存率相关。将“教科书式结局”用作辅助指标可全面了解患者和中心的结局。
