Changes in Use of Left Ventricular Assist Devices as Bridge to Transplantation With New Heart Allocation Policy
Changes in Use of Left Ventricular Assist Devices as Bridge to Transplantation With New Heart Allocation Policy
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DOI：
10.1016/j.jchf.2021.01.010
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发表时间：
2021-05-31
影响因子：
13
通讯作者：
Ahmad, Tariq
中科院分区：
文献类型：
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作者：
Mullan, Clancy W.;Chouairi, Fouad;Ahmad, Tariq
本研究的目的是描述心脏移植桥（BTT）患者在供体心脏分配系统发生变化后的结局。背景左心室辅助装置（LVAD）已被用作BTT。2018年10月18日，美国供体心脏分配系统更新。方法本研究确定了器官共享联合网络数据库中的成人，在2017年4月至2020年4月期间上市或植入时具有持久的连续流LVAD。基线受体和供体的特征，等待名单的生存，移植后的结果进行了比较前和后分配系统的变化。结果共有1,794例患者符合纳入标准：983在前的变化期间和814后。随着时间的推移，全国LVAD患者的数量从2017年4月的102人减少到2020年4月的12人（p < 0.001）。移植时LVAD患者的比例从47%降至14%。在改变之前，移植时大多数为状态1A（75.8%）;之后，大多数为状态2/3（67.8%）。移植率没有差异（85.4% vs. 83.6%; p = 0.225），但等待时间在后期减少（82 vs. 65天; p = 0.004）。供体更可能是高风险（39.0%对32.2%; p = 0.005），缺血时间和行驶距离均增加（3.4小时对3.1小时; p < 0.001; 199英里对82英里; p < 0.001）。等待名单的存活率没有改变，但移植后存活率在BTT患者中更差（p < 0.001）。结论：移植名单上的BTT患者数量在分配系统改变后稳定而显著地下降。虽然移植时间缩短，但移植后死亡率增加。这些数据表明，在新的分配系统下，LVAD植入作为BTT的风险和受益发生了变化，并且该治疗策略的适当适应症需要重新评估。(C)2021年由美国心脏病学会基金会。
OBJECTIVES The goal of this study was to describe outcomes of patients with bridge to heart transplantation (BTT) after changes were made to the donor heart allocation system.BACKGROUND Left ventricular assist devices (LVADs) have been used as a BTT. On October 18, 2018, the donor heart allocation system in the United States was updated.METHODS This study identified adults in the United Network for Organ Sharing database with durable, continuous-flow LVAD at listing or implanted while listed between April 2017 and April 2020. Baseline recipient and donor characteristics, waitlist survival, and post-transplantation outcomes were compared pre- and post-allocation system change.RESULTS A total of 1,794 patients met inclusion criteria: 983 in the pre-change period and 814 afterward. The number of patients listed with LVAD decreased nationally over time from 102 in April 2017 to 12 in April 2020 (p < 0.001). The proportion of patients with LVAD at time of transplant decreased from 47% to 14%. Before the change, the majority were Status 1A (75.8%) at transplantation; afterward, most were Status 2/3 (67.8%). Transplantation rates were not different (85.4% vs. 83.6%; p = 0.225), but waitlist time decreased in the post period (82 vs. 65 days; p = 0.004). Donors were more likely to be high risk (39.0% vs. 32.2%; p = 0.005), and both ischemic times and distance traveled increased (3.4 h vs. 3.1 h; p < 0.001; 199 miles vs. 82 miles; p < 0.001). Waitlist survival did not change, but post-transplantation survival was worse in patients with BTT post-change (p < 0.001).CONCLUSIONS The number of patients with BTT on the transplant list decreased steadily and dramatically after the allocation system change. Although time to transplant decreased, there was an increase in post-transplant mortality. These data suggest that the risks and benefits of LVAD implantation as a BTT have changed under the new allocation system and that the appropriate indication for this treatment strategy warrants a re-evaluation. (C) 2021 by the American College of Cardiology Foundation.