Use of Temporary Mechanical Circulatory Support for Management of Cardiogenic Shock Before and After the United Network for Organ Sharing Donor Heart Allocation System Changes
Use of Temporary Mechanical Circulatory Support for Management of Cardiogenic Shock Before and After the United Network for Organ Sharing Donor Heart Allocation System Changes
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DOI：
10.1001/jamacardio.2020.0692
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发表时间：
2020-06-01
期刊：
影响因子：
24
通讯作者：
Morrow, David A.
中科院分区：
文献类型：
--
作者：
Varshney, Anubodh S.;Berg, David D.;Morrow, David A.
问题 新的联合器官共享网络 (UNOS) 供体心脏分配系统的实施是否与三级心脏重症监护病房中用于治疗心源性休克的临时机械循环支持的使用变化相关，以及美国移植中心、美国非移植中心和加拿大中心之间的使用是否存在差异？结果 在这项来自北美 14 个中心的队列研究中，在 UNOS 供体心脏分配系统修订后的一年内，在 384 名因急性失代偿性心力衰竭相关心源性休克入院的患者中，美国移植中心临时机械循环支持的使用显着增加，但其他心脏重症监护病房没有显着增加，其他形式的心源性休克也没有增加。含义 UNOS 供体心脏分配系统的变化可能与美国移植中心的从业者对急性、失代偿、心力衰竭相关心源性休克患者的管理策略的变化有关。这项队列研究探讨了器官共享联合网络供体心脏分配系统的修订与临时机械循环支持的使用之间的关系，以及美国移植中心、美国非移植中心和加拿大中心之间临时机械循环支持的使用是否存在差异。新的器官共享联合网络的重要性(UNOS) 供体心脏分配系统优先考虑在等待心脏移植期间接受不可放电机械循环支持 (MCS) 装置支持的患者。自该政策实施以来，心脏重症监护病房 (CICU) 中临时 MCS 的使用是否发生变化尚不清楚。目的 研究 2018 年 10 月 UNOS 供者心脏分配系统修订是否与 CICU 中临时 MCS 使用的变化相关，以及美国移植中心、美国非移植中心和加拿大中心之间临时 MCS 使用是否存在差异。设计、设置和参与者在这项队列研究中，来自北美三级 CICU 多中心网络重症监护心脏病学试验网络 (CCCTN) 的 14 个中心提供了 2017 年 9 月 1 日至 2018 年 9 月 1 日（修订前期）以及 2018 年 10 月 1 日至 2019 年 9 月 1 日（修订后）连续 CICU 入院的 2 个月快照。期）。 CICU 分为美国移植中心 (n = 7) 或其他 CICU（美国非移植中心或加拿大中心；n = 7）。 UNOS 捐献者心脏分配系统的修订。主要结果和措施 入院期间接受临时 MCS 治疗（主动脉内球囊反搏器、微轴心内心室辅助装置、经皮离心心室辅助装置、静脉动脉体外膜氧合或手术植入、不可排出的 MCS 装置）。结果 共纳入 384 例因急性失代偿性心力衰竭相关心源性休克 (ADHF-CS) 入院的患者，其中 248 例 (64.6%) 前往美国移植中心； 126 例 (51%) 处于修订前阶段，122 例 (49%) 处于修订后阶段。患者平均年龄 (SD) 为 61.2 (14.6) 岁； 246 名患者（64.1%）为男性。美国移植中心接受临时 MCS 管理的 ADHF-CS 入院比例从 UNOS 分配系统变更前的 25.4%（126 例入院中的 32 例）显着增加到 42.6%（122 例入院中的 52 例）（P = .004）。在其他 CICU，这一比例没有显着变化（24.5% [53 名入院者中的 13 名] 升至 24.1% [83 名入院者中的 20 名]；P = .95）。经过多变量调整后，与翻修前入住的患者相比，翻修后入住美国移植中心的患者更有可能接受临时 MCS（调整后优势比，2.19；95% CI，1.13-4.24；P = .02）。结论和相关性 在实施新的 UNOS 供体心脏分配系统一年后，美国移植中心因 ADHF-CS 入院的患者临时 MCS 的使用有所增加，但其他 CICU 没有增加。应评估这种实践转变是否会影响 ADHF-CS 患者的结局或器官分布。
Question Was implementation of the new United Network for Organ Sharing (UNOS) donor heart allocation system associated with changes in the use of temporary mechanical circulatory support for the management of cardiogenic shock in tertiary cardiac intensive care units, and did use differ between US transplant centers and US nontransplant centers and Canadian centers? Findings In this cohort study from 14 centers in North America, among 384 patients admitted with acute, decompensated, heart failure-related cardiogenic shock, the use of temporary mechanical circulatory support increased significantly in US transplant centers but not in other cardiac intensive care units and not for other forms of cardiogenic shock in the year after the UNOS donor heart allocation system revisions. Meaning Changes in the UNOS donor heart allocation system may have been associated with changes in practitioners' management strategies for patients with acute, decompensated, heart failure-related cardiogenic shock at US transplant centers.This cohort study examines the association of revisions to the United Network for Organ Sharing donor heart allocation system with use of temporary mechanical circulatory support and whether temporary mechanical circulatory support use differed between US transplant centers and US nontransplant centers and Canadian centers.Importance The new United Network for Organ Sharing (UNOS) donor heart allocation system gives priority to patients supported with nondischargeable mechanical circulatory support (MCS) devices while awaiting heart transplant. Whether there has been a change in temporary MCS use in cardiac intensive care units (CICUs) since the implementation of this policy is unknown. Objectives To examine whether the UNOS donor heart allocation system revision in October 2018 was associated with changes in temporary MCS use in CICUs and whether temporary MCS use differed between US transplant centers and US nontransplant centers and Canadian centers. Design, Setting, and Participants In this cohort study, 14 centers from the Critical Care Cardiology Trials Network (CCCTN), a multicenter network of tertiary CICUs in North America, contributed 2-month snapshots of consecutive medical CICU admissions between September 1, 2017, and September 1, 2018 (prerevision period), and October 1, 2018, and September 1, 2019 (postrevision period). CICUs were classified as US transplant centers (n = 7) or other CICUs (US nontransplant centers or Canadian centers; n = 7). Exposure Revision to the UNOS donor heart allocation system. Main Outcomes and Measures Treatment with temporary MCS (intra-aortic balloon pump, microaxial intracardiac ventricular assist device, percutaneous centrifugal ventricular assist device, venoarterial extracorporeal membrane oxygenation, or surgically implanted, nondischargeable MCS device) during hospital admission. Results A total of 384 admissions for acute, decompensated, heart failure-related cardiogenic shock (ADHF-CS) were included, among which 248 (64.6%) were to US transplant centers; 126 admissions (51%) were in the prerevision period and 122 (49%) were in the postrevision period. The mean (SD) patient age was 61.2 (14.6) years; 246 patients (64.1%) were male. The proportion of admissions with ADHF-CS managed with temporary MCS at US transplant centers significantly increased from 25.4% (32 of 126 admissions) before to 42.6% (52 of 122 admissions) after the UNOS allocation system changes (P = .004). In other CICUs, the proportion did not significantly change (24.5% [13 of 53 admissions] to 24.1% [20 of 83 admissions]; P = .95). After multivariable adjustment, patients admitted to US transplant centers in the postrevision period were more likely to receive temporary MCS compared with those admitted in the prerevision period (adjusted odds ratio, 2.19; 95% CI, 1.13-4.24; P = .02). Conclusions and Relevance In the year after implementation of the new UNOS donor heart allocation system, temporary MCS use in patients admitted with ADHF-CS increased in US transplant centers but not in other CICUs. Whether this shift in practice will affect outcomes of patients with ADHF-CS or organ distribution should be evaluated.