Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.
Pediatric Cardiology, Nationwide Children's Hospital, Columbus, Ohio, USA.
Pediatr Transplant. 2024 Jun;28(4):e14787. doi: 10.1111/petr.14787.
Children awaiting heart transplant (Tx) have a high risk of death due to donor organ scarcity. Historically, ventricular assist devices (VADs) reduced waitlist mortality, prompting increased VAD use. We sought to determine whether the VAD survival benefit persists in the current era.
Using the Scientific Registry of Transplant Recipients, we identified patients listed for Tx between 3/22/2016 and 9/1/2020. We compared characteristics of VAD and non-VAD groups at Tx listing. Cox proportional hazards models were used to identify risk factors for 1-year waitlist mortality.
Among 5054 patients, 764 (15%) had a VAD at Tx listing. The VAD group was older with more mechanical ventilation and renal impairment. Unadjusted waitlist mortality was similar between groups; the curves crossed ~90 days after listing (p = .55). In multivariable analysis, infant age (HR 2.77, 95%CI 2.13-3.60), Black race (HR 1.57, 95%CI 1.31-1.88), congenital heart disease (HR 1.23, 95%CI 1.04-1.46), renal impairment (HR 2.67, 95%CI 2.19-3.26), inotropes (HR 1.28, 95%CI 1.09-1.52), and mechanical ventilation (HR 2.23, 95%CI 1.84-2.70) were associated with 1-year waitlist mortality. VADs were not associated with mortality in the first 90 waitlist days but were protective for those waiting ≥90 days (HR 0.43, 95%CI 0.26-0.71).
In the current era, VADs reduce waitlist mortality, but only for those waitlisted ≥90 days. The differential effect by race, size, and VAD type is less clear. These findings suggest that Tx listing without VAD may be reasonable if a short waitlist time is anticipated, but VADs may benefit those expected to wait >90 days.
由于供体器官稀缺，等待心脏移植（Tx）的儿童死亡风险很高。从历史上看，心室辅助装置（VAD）降低了候补名单上的死亡率，促使更多地使用 VAD。我们试图确定在当前时代，VAD 是否具有生存优势。
我们使用移植受者科学注册处，确定了 2020 年 9 月 1 日至 2020 年 9 月 1 日期间 Tx 上市的患者。我们比较了 VAD 和非 VAD 组在 Tx 上市时的特征。Cox 比例风险模型用于确定 1 年候补名单死亡率的危险因素。
在 5054 名患者中，有 764 名（15%）在 Tx 上市时使用了 VAD。VAD 组年龄较大，需要更多的机械通气和肾功能损害。两组之间的未调整候补名单死亡率相似；曲线在上市后约 90 天（p=0.55）交叉。多变量分析显示，婴儿年龄（HR 2.77，95%CI 2.13-3.60）、黑种人（HR 1.57，95%CI 1.31-1.88）、先天性心脏病（HR 1.23，95%CI 1.04-1.46）、肾功能损害（HR 2.67，95%CI 2.19-3.26）、正性肌力药（HR 1.28，95%CI 1.09-1.52）和机械通气（HR 2.23，95%CI 1.84-2.70）与 1 年候补名单死亡率相关。在头 90 天的候补名单中，VAD 与死亡率无关，但对于等待时间≥90 天的患者是有保护作用的（HR 0.43，95%CI 0.26-0.71）。
在当前时代，VAD 降低了候补名单上的死亡率，但仅对等待时间≥90 天的患者有效。种族、体型和 VAD 类型的差异影响尚不清楚。这些发现表明，如果预计候补名单时间较短，Tx 上市而不使用 VAD 可能是合理的，但 VAD 可能使预计等待时间>90 天的患者受益。
