Modern Outcomes of Mechanical Circulatory Support as a Bridge to Pediatric Heart Transplantation

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• 作者：Brody Wehman ; MD^a ; Kristen A. Stafford ; MPH^b ; Gregory J. Bittle ; MD^a ; Zachary N. Kon ; MD^a ; Charles F. Evans ; MD^a ; Keshava Rajagopal ; MD ; PhD^a ; Nicholas Pietris ; MD^c ; Sunjay Kaushal ; MD ; PhD^a ; Bartley P. Griffith ; MD^a ; ^{bgriffith@smail.umaryland.edu" class="auth_mail" title="E-mail the corresponding author}
• 关键词：BTT ; bridge to transplantation ; CI ; confidence interval ; DTXP ; direct transplantation ; ECMO ; extracorporeal membrane oxygenation ; HR ; hazard ratio ; MCS ; mechanical circulatory support ; UNOS ; United Network for Organ Sharing ; VAD ; ventricular assist device
• 刊名：The Annals of Thoracic Surgery
• 出版年：2016
• 出版时间：June 2016
• 年：2016
• 卷：101
• 期：6
• 页码：2321-2327
• 全文大小：349 K

文摘

Pediatric patients awaiting orthotopic heart transplantation frequently require bridge to transplantation (BTT) with mechanical circulatory support. Posttransplant survival outcomes and predictors of mortality have not been thoroughly described in the modern era using a large-scale analysis.

Methods

ra0015">The United Network for Organ Sharing database was reviewed to identify pediatric heart transplant recipients from 2005 through 2012. Patients were stratified into three groups: extracorporeal membrane oxygenation (ECMO), ventricular assist device (VAD), and direct transplantation (DTXP). The primary outcome was posttransplant survival.

Results

ra0020">Two thousand seven hundred seventy-seven pediatric patients underwent orthotopic heart transplantation. There were 617 patients who required BTT with mechanical circulatory support (22.2%), of whom there were 428 VAD BTT (69.4%) and 189 ECMO BTT (30.6%). An increase in VAD use was observed during the study period (p < 0.0001). Compared with DTXP, patients in the ECMO BTT group had a lower median age (<1 versus 5 years; p < 0.0001) and were significantly smaller (8 versus 14 kg; p < 0.001), whereas patients in the VAD BTT group were older (8 versus 5 years; p = 0.0002) and larger (24 versus 14 kg; p < 0.001). Actuarial survival was greater in the DTXP group compared with ECMO BTT, but similar to VAD BTT at 30 days and 1, 3, and 5 years. However, this survival difference was lost after censoring the first 4 months after transplant. In multivariable analysis, when restricted to the first 4 months of survival, independent predictors for mortality were ECMO BTT, age, diagnosis, and functional status, whereas VAD BTT was not.

Conclusions

ra0025">Pediatric patients with DTXP or VAD BTT have equivalent posttransplant survival. However, those requiring ECMO BTT have inferior early posttransplant survival compared with those receiving DTXP.