机械循环支持在严重原发性移植物功能障碍中的应用：外周插管而非更早植入可改善心脏移植的存活率。
Mechanical circulatory support in severe primary graft dysfunction: Peripheral cannulation but not earlier implantation improves survival in heart transplantation.
机构信息
Heart Failure Unit, Cardiology Department, Hospital Universitari Vall d'Hebrón, Vall d'Hebrón Institut de Recerca, Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain.
Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain; Heart Failure and Transplant Unit, Cardiology department, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
出版信息
J Heart Lung Transplant. 2023 Aug;42(8):1101-1111. doi: 10.1016/j.healun.2023.03.008. Epub 2023 Mar 15.
BACKGROUND
Primary graft dysfunction (PGD) still affects 2% to 28% of heart transplants (HT). Severe PGD requires mechanical circulatory support (MCS) and is the main cause of death early after HT. Earlier initiation has been suggested to improve prognosis but the best cannulation strategy is unknown.
METHODS
Analysis of all HT in Spain between 2010 and 2020. Early (<3 hours after HT) vs late initiation (≥3 hours after HT) of MCS was compared. Special focus was placed on peripheral vs central cannulation strategy.
RESULTS
A total of 2376 HT were analyzed. 242 (10.2%) suffered severe PGD, 171 (70.7%) received early MCS and 71 (29.3%) late MCS. Baseline characteristics were similar. Patients with late MCS had higher inotropic scores and worse renal function at the moment of cannulation. Early MCS had longer cardiopulmonary bypass times and late MCS was associated with more peripheral vascular damage. No significant differences in survival were observed between early and late implant at 3 months (43.82% vs 48.26%; log-rank p = 0.59) or at 1 year (39.29% vs 45.24%, log-rank p = 0.49). Multivariate analysis did not show significant differences favoring early implant. Survival was higher in peripheral compared to central cannulation at 3 months (52.74% vs 32.42%, log-rank p = 0.001) and 1 year (48.56% vs 28.19%, log-rank p = 0.0007). In the multivariate analysis, peripheral cannulation remained a protective factor.
CONCLUSIONS
Earlier MCS initiation for PGD was not superior, compared to a more conservative approach with deferred initiation. Peripheral compared to central cannulation showed superior 3-month and 1-year survival rates.
背景
原发性移植物功能障碍（PGD）仍然影响 2%至 28%的心脏移植（HT）。严重的 PGD 需要机械循环支持（MCS），是 HT 后早期死亡的主要原因。有研究表明早期开始可以改善预后，但最佳的置管策略尚不清楚。
方法
分析 2010 年至 2020 年期间西班牙所有的 HT。比较了 MCS 的早期（HT 后 3 小时内）与晚期（HT 后 3 小时后）开始。特别关注外周与中央置管策略。
结果
共分析了 2376 例 HT。242 例（10.2%）发生严重 PGD，171 例（70.7%）接受早期 MCS，71 例（29.3%）接受晚期 MCS。基线特征相似。晚期 MCS 患者置管时的正性肌力评分更高，肾功能更差。早期 MCS 的体外循环时间更长，晚期 MCS 与更多的外周血管损伤有关。在 3 个月（43.82% vs 48.26%；对数秩检验 p=0.59）或 1 年（39.29% vs 45.24%，对数秩检验 p=0.49）时，早期与晚期植入的存活率没有显著差异。多变量分析也没有显示出早期植入的显著优势。在 3 个月（52.74% vs 32.42%，对数秩检验 p=0.001）和 1 年（48.56% vs 28.19%，对数秩检验 p=0.0007）时，外周置管的存活率高于中央置管。在多变量分析中，外周置管仍然是一个保护因素。
结论
与延迟开始的更保守方法相比，PGD 早期开始 MCS 并没有优势。与中央置管相比，外周置管的 3 个月和 1 年存活率更高。
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