Left Ventricular Assist Device Destination Therapy Versus Extended Criteria Cardiac Transplant
Left Ventricular Assist Device Destination Therapy Versus Extended Criteria Cardiac Transplant
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DOI：
10.1016/j.athoracsur.2009.12.058
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发表时间：
2010-04-01
影响因子：
4.6
通讯作者：
Milano, Carmelo A.
中科院分区：
文献类型：
--
作者：
Daneshmand, Mani A.;Rajagopal, Keshava;Milano, Carmelo A.
背景。终末期心力衰竭是一个日益严重的问题，与使用传统医疗保健的高死亡率相关。虽然心脏移植是一个很好的治疗选择，但它是一个有限的资源，大多数患者不符合心脏移植的标准列表标准。对于这些患者，越来越多的新手术选择包括在扩展标准替代清单心脏移植计划（EC-AL）中使用边缘供体器官，或将左心室辅助装置作为目标治疗（DT-LVAD）。本研究的目的是比较EC-AL和dt - lvad后的基线特征和结果。从2000年3月到2008年8月，153名连续拒绝接受标准心脏移植的患者接受了EC-AL或DT-LVAD。两组患者不适合标准心脏移植的最常见原因是高龄、糖尿病伴终末器官功能障碍和明显的肾功能不全。备选名单项目的患者接受了一个被所有其他标准名单接受者中心拒绝的捐赠器官。供体心脏拒绝的最常见原因是左心室功能下降、左心室肥厚或冠状动脉疾病。在获得机构审查委员会许可后，对两组的结果进行回顾性审查。通过倾向评分分析匹配的患者之间也进行了比较。总共有93例患者接受了EC-AL， 60例接受了DT-LVAD。两组的基线术前特征相似，除了87%的DT-LVAD患者（60人中有52人）需要术前机械或肌力支持，而只有51%的EC-AL患者（93人中有47人）需要支持（p < 0.0001）。EC-AL组30天手术死亡率和1年生存率分别为2.5%和82.2%，DT-LVAD组为6.7%和77.5% （p = 0.2411和p = 0.5036）。3年的总生存率EC-AL优于DT-LVAD。与机械辅助治疗充血性心力衰竭随机评价（REMATCH）试验DT-LVAD队列相比，DT-LVAD患者的生存率有所提高。这些发现在对倾向匹配患者的分析中得到了证实。术前，DT-LVAD患者更不稳定，更需要肌力或机械支持。尽管如此，两组的围手术期和1年死亡率相似。EC-AL的3年生存率更高。DT-LVAD患者的生存率优于REMATCH DT-LVAD队列。（Ann Thorac surgery 2010; 89: 1205-10） (C) 2010年由胸外科学会出版
Background. End-stage heart failure is a growing problem associated with a high mortality using conventional medical care. Although cardiac transplantation is an excellent treatment option, it is a limited resource and most patients are ineligible for cardiac transplantation using standard listing criteria. Increasingly, newer surgical options for these patients include the usage of marginal donor organs in an extended criteria-alternate list heart transplant program (EC-AL), or left ventricular assist devices as destination therapy (DT-LVAD). The purpose of this study was to compare baseline characteristics and outcomes after EC-AL versus DT-LVAD.Methods. From March 2000 to August 2008, 153 consecutive patients who had been turned down for standard heart transplantation underwent either EC-AL or DT-LVAD. The most common reasons for standard heart transplant ineligibility for both groups were advanced age, diabetes mellitus with end-organ dysfunction, and significant renal insufficiency. Patients in the alternate list program received a donor organ that had been turned down by all other centers for standard list recipients. The most common reasons for donor heart refusal were decreased left ventricular function, left ventricle hypertrophy, or coronary artery disease. Outcomes for both groups were retrospectively reviewed after Institutional Review Board permission was obtained. Comparisons were also made between patients that had been matched by propensity score analysis.Results. In all, 93 patients underwent EC-AL, and 60 underwent DT-LVAD. Baseline preoperative characteristics of both groups were similar except that 87% of DT-LVAD patients (52 of 60) required preoperative mechanical or inotropic support whereas only 51% of EC-AL patients (47 of 93) required support (p < 0.0001). Thirty-day operative mortality and 1-year survival were 2.5% and 82.2% for EC-AL and 6.7% and 77.5% DT-LVAD, respectively (p = 0.2411 and p = 0.5036). Overall survival at 3 years was better for EC-AL versus DT-LVAD. The DT-LVAD patients had improved survival compared with the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial DT-LVAD cohort, a historical control. These findings were corroborated in the analysis of propensity-matched patients.Conclusions. Preoperatively, the DT-LVAD cohort was more unstable, with greater need for inotropes or mechanical support. Despite this, perioperative and 1-year mortality was similar for the two groups. Three-year survival was better for EC-AL. The DT-LVAD patient survival was better than that of the REMATCH DT-LVAD cohort. (Ann Thorac Surg 2010; 89: 1205-10) (C) 2010 by The Society of Thoracic Surgeons