Frigerio M, Gronda E G, Mangiavacchi M, Andreuzzi B, Colombo T, De Vita C, Oliva F, Quaini E, Pellegrini A
De Gasperis Cardiac Surgery & Cardiology Center, Niguarda-Ca' Granda Hospital, Milan, Italy.
J Heart Lung Transplant. 1997 Feb;16(2):160-8.
The shortage of organ donors and the amelioration of medical management of advanced heart failure mandate strict selection of heart transplant candidates on the basis of the need and probability of success of transplantation, with the aim of maximizing survival of patients with advanced heart failure, both with and without transplantation. This study analyzes the impact of restricting the criteria for heart transplantation candidacy on the outcome of patients with advanced heart failure referred for transplantation.
Survival and freedom from major cardiac events (death, resuscitated cardiac arrest, transplantation while supported with inotropes or mechanical devices) were compared between patients listed during 1990 to 1991, when standard criteria were applied (group 1, n = 118), and patients listed during 1993 to 1994, when only patients requiring continuous/recurrent intravenous inotrope therapy in spite of optimized oral medications and outpatients showing actual progression of the disease were admitted to the waiting list (group 2, n = 88). Survival and freedom from cardiac events (defined as above plus listing in urgent status) were also calculated in stable outpatients evaluated in 1993 to 1994, who were potential heart transplant candidates according to standard criteria but were not listed because of restrictive criteria (group 3, n = 52, New York Heart Association functional class > or = III, mean echocardiographic ejection fraction 0.22 +/- 0.05, mean peak oxygen consumption 12.3 +/- 1.5 ml/kg/min, mean follow-up 19 +/- 10 months).
Thirty-one percent, 40%, and 50% of group 1 patients versus 58%, 65%, and 77% of group 2 patients underwent transplantation within 3, 6, and 12 months after listing (p < 0.0007). The 1- and 2-year survival rates after listing were 80% and 71% in group 1 versus 85% and 84% in group 2 (p < 0.0001). Freedom from death/urgent transplantation was lower in group 2 than in group 1 (55% and 48% versus 72% and 59% at 6 and 12 months, respectively; p < 0.0001). In patients undergoing transplantation, the postoperative survival rate was similar (87% and 91% at 2 years in group 1 and group 2, respectively). Two years after heart transplantation candidacy was denied, 86% of group 3 patients were alive, and 74% were event-free.
Restricting the admissions to the waiting list to patients with refractory/progressive heart failure improved survival rates after listing by increasing the probability to undergo transplantation in a short time. Selection of most severely ill candidates did not affect postoperative survival. Survival and freedom from cardiac events were good in patients with advanced but stable heart failure, in spite of their severe functional limitation. Thus restrictive criteria for heart transplantation candidacy allows maximal survival benefit from both medical therapy and transplantation.
器官捐献者的短缺以及晚期心力衰竭医疗管理的改善，要求根据移植的必要性和成功的可能性对心脏移植候选者进行严格筛选，目的是使晚期心力衰竭患者无论是否接受移植都能最大限度地提高生存率。本研究分析了限制心脏移植候选标准对转诊接受移植的晚期心力衰竭患者预后的影响。
比较了1990年至1991年采用标准标准时登记的患者（第1组，n = 118）和1993年至1994年登记的患者，后者仅将尽管口服药物优化但仍需要持续/反复静脉内使用正性肌力药物治疗的患者以及门诊显示疾病实际进展的患者列入等待名单（第2组，n = 88）的生存率和无重大心脏事件（死亡、复苏的心脏骤停、在使用血管活性药物或机械装置支持下进行移植）的情况。还计算了1993年至1994年评估的稳定门诊患者的生存率和无心脏事件（定义同上并加上紧急状态下登记）的情况，这些患者根据标准标准是潜在的心脏移植候选者，但由于限制标准未被列入名单（第3组，n = 52，纽约心脏协会功能分级≥III级，平均超声心动图射血分数0.22±0.05，平均峰值耗氧量12.3±1.5 ml/kg/min，平均随访19±10个月）。
第1组患者在登记后3、6和12个月内接受移植的比例分别为31%、40%和50%，而第2组患者分别为58%、65%和77%（p < 0.0007）。登记后的1年和2年生存率，第1组为80%和71%，第2组为85%和84%（p < 0.0001）。第2组无死亡/紧急移植的比例低于第1组（6个月和12个月时分别为55%和48%，而第1组为72%和59%；p < 0.0001）。在接受移植的患者中，术后生存率相似（第1组和第2组在2年时分别为87%和91%）。在被拒绝心脏移植候选资格两年后，第3组患者中有86%存活，74%无事件发生。
将等待名单的准入限制为难治性/进行性心力衰竭患者，通过增加短期内接受移植的可能性提高了登记后的生存率。选择病情最严重的候选者并不影响术后生存率。尽管晚期心力衰竭患者功能严重受限，但病情稳定的患者生存率和无心脏事件情况良好。因此，心脏移植候选资格的限制标准能使药物治疗和移植都获得最大的生存益处。
