Age and Outcome After Continuous-Flow Left Ventricular Assist Device Implantation as Bridge to Transplantation (original) (raw)
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Interactive CardioVascular and Thoracic Surgery, 2016
OBJECTIVES: In Europe, the age of heart donors is constantly increasing. Ageing of heart donors limits the probability of success of heart transplantation (HTx). The aim of this study is to compare the outcome of patients with advanced heart failure (HF) treated with a continuous-flow left ventricular assist device (CF-LVAD) with indication as bridge to transplantation (BTT) or bridge to candidacy (BTC) versus recipients of HTx with the donor's age above 55 years (HTx with donors >55 years). METHODS: we prospectively evaluated 301 consecutive patients with advanced HF treated with a CF-LVAD (n = 83) or HTx without prior bridging (n = 218) in our hospital from January 2006 to January 2015. We compared the outcome of CF-LVAD-BTT (n = 37) versus HTx with donors >55 years (n = 45) and the outcome of CF-LVAD-BTT plus BTC (n = 62) versus HTx with donors >55 years at the 1-and 2-year follow-up. Survival was evaluated according to the first operation. RESULTS: The perioperative (30-day) mortality rate was 0% in the LVAD-BTT group vs 20% (n = 9) in the HTx group with donors >55 years (P = 0.003). Perioperative mortality occurred in 5% of the LVAD-BTT/BTC patients (n = 3) and in 20% of the HTx with donors >55 year group (P = 0.026). Kaplan-Meier curves estimated a 2-year survival rate of 94.6% in CF-LVAD-BTT vs 68.9% in HTx with donors >55 years [ageand sex-adjusted hazard ratio (HR) 0.25; 95% confidence interval (CI) 0.08-0.81; P = 0.02 in favour of CF-LVAD]. Considering the post-HTx outcome, a trend in favour of CF-LVAD-BTT was also observed (age-and sex-adjusted HR 0.45; 95% CI 0.17-1.16; P = 0.09 in favour of CF-LVAD), whereas CF-LVAD-BTT/BTC showed a similar survival at 2 years compared with HTx with donors >55 years, both censoring the follow-up at the time of HTx and considering the post-HTx outcome. CONCLUSIONS: Early and mid-term outcomes of patients treated with a CF-LVAD with BTT indication seem better than HTx with old donors. It must be emphasized that up to 19% of patients in the CF-LVAD/BTT group underwent transplantation in an urgent condition due to complications related to the LVAD. At the 2-year follow-up, CF-LVAD with BTT and BTC indications have similar outcome than HTx using old heart donors. These results must be confirmed in a larger and multicentre population and extending the follow-up.
International Journal of Cardiology, 2021
Background: Geographic variations in management and outcomes of individuals supported by continuous-flow left ventricular assist devices (CF-LVAD) between the United States (US) and Europe (EU) is largely unknown. Methods: We created a retrospective, multinational registry of 524 patients who received a CF-LVAD (either HVAD or Heartmate II) between January 2008 and April 2017. Follow up spanned from date of CF-LVAD implant to post-HTx period with a median follow up of 44.8 months. Results: The cohort included 299 (57.1%) EU and 225 (42.9%) US patients. Although the US cohort was significantly older with a higher prevalence of comorbidities, survival was similar between the cohorts (US 63.1%, EU 68.4% at 5 years, unadjusted log-rank test p = 0.43).Multivariate analyses suggested that older age, higher body mass index, elevated creatinine, use of temporary mechanical circulatory support prior CF-LVAD, and implantation of HVAD were associated with increased mortality. Among CF-LVAD patients undergoing HTx, the median time on CF-LVAD support was shorter in the US, meanwhile US donors were younger. Finally, the pattern of adverse events (stroke, gastrointestinal bleedings, late right ventricular failure, and driveline infection) during support differed significantly between US and EU. Conclusions: Although waitlisted patients in the US on CF-LVAD have higher risk comorbid conditions, the overall outcome is similar in US and EU. Geographic variations with regards to donor characteristics, duration of CF-LVAD support prior to transplant, and adverse events on support can explain the disparity in the utilization of mechanical bridge to transplant strategy between US and EU.
Journal of Cardiac Failure, 2014
Published data on mechanical circulatory support for elderly patients in continuous flow devices are sparse and suggest relatively poor survival. This study investigated whether LVADs can be implanted in selected patients over the age of 65 years with acceptable survival compared with published outcomes. A single-center retrospective analysis was conducted in 64 consecutive patients ≥65 years of age implanted with a continuous-flow left ventricular assist device (CF-LVAD) as either bridge to transplantation or destination therapy from August 2005 to January 2012. Baseline laboratory and hemodynamic characteristics and follow-up data were obtained. Median survival was 1,090 days. Survival was 85%, 74%, 55%, and 45% at 6 months and 1, 2, and 3 years, respectively. Our cohort had a baseline mean Seattle Heart Failure Model (SHFM) score of 2.6 ± 0.9. Observed survival was significantly better than SHFM-predicted medical survival. Stratification by age subsets, renal function, SHFM, implantation intention, or etiology did not reveal significant differences in survival. The most common cause of death was sepsis and nonlethalcomplication was bleeding. Our experience with patients over the age of 65 receiving CF-LVADs suggests that this group demonstrates excellent survival. Further research is needed to discern the specific criteria for risk stratification for LVAD support in the elderly.
513: One Year Followup with a Continuous Flow LVAD as a Bridge to Heart Transplantation
The Journal of Heart and Lung Transplantation, 2008
Purpose: Despite the high priority allocation and availability of mechanical circulatory support (MCS), 18% of the medically managed UNOS status 1A candidates die without MCS while awaiting heart transplantation (HT). Decision to advance therapy to MCS is often difficult, as there are no strict criteria who and when would be most likely to benefit from BTT. In order to identify pts, for whom MCS would be favored over waiting for HT, we analyzed outcomes of the U.S. population of medically managed status 1A candidates. Methods and Materials: Between Jan 2000 and Dec 2006, a total of 3,711 pts were listed de novo as UNOS status 1A candidates in the U.S., including 2,208 (59%) who were initially treated medically and 1,503 (41%) rescued with BTT before the day of listing. Of the 2,208 medically managed pts, 451 (20%) subsequently underwent BTT. Pts were followed until HT, death, removal from the waiting list or Sept 1, 2007. Results: The use of MCS in medically managed status 1A candidates was associated with increased probability of survival and/or HT from 66.5% to 87.1% at 3-months*. By multivariate analysis the risk factors for death and/or not receiving HT within 24 days (median time to HT) in medically managed pts included the presence of intra-aortic balloon pump* or ventilator support*, SCr Ͼ 1.5 mg%*, age Ͼ 60 yrs*, albumin Յ 2.5 g%*, ABO blood type O* and weight Ͼ 89 kg*. The time when the predicted probability of 1-month survival and/or HT decreased below the average 85% 1-month survival benefit of MCS alone, varied between days and weeks depending on the pts risk profile. Conclusions: Elective MCS implantation as BTT should be strongly considered in medically managed UNOS status 1A candidates at high risk of death and/or anticipated long waiting time to HT. The predicted 1-month survival in pts with the identified risk factors for death or with projected long wait times to HT may help guide the optimal timing for device implantation. * pϽ0.001.
Mid-term survival after continuous-flow left ventricular assist device versus heart transplantation
Heart and Vessels, 2015
Background-There is a paucity of data about mid-term outcome of patients with advanced heart failure (HF) treated with left ventricular assist device (LVAD) in Europe, where donor shortage and their aging limit the availability and the probability of success of heart transplantation (HTx). The aim of this study is to compare Italian single-centre mid-term outcome in prospective patients treated with LVAD versus HTx.
The Annals of Thoracic Surgery, 2013
INTRODUCTION-Although orthotopic heart transplantation (OHT) is increasingly being offered to older patients, few studies have evaluated outcomes in patients over the age of 70 years. We undertook this study to characterize the outcomes of septuagenarians bridged to heart transplantation (BTT) in the modern era. METHODS-We conducted a retrospective cohort study of all adult OHT in the United Network for Organ Sharing database from 2005-2011. Primary stratification was by age≥70 years. Subgroup analysis evaluated BTT patients. The primary outcome was survival as determined by the Kaplan-Meier method. RESULTS-From 01/2005-12/2011, 12,274 adults underwent OHT, including 3,243 (26.4%) who were BTT. In the entire cohort, 11,996 (97.7%) recipients were ages 18-70, and 277 (2.3%) were ≥70 years of age. Overall, OHT patients ≥70 had decreased 90-day (93.6 vs 88.8%, p<0.01), 1-year (89.0 vs 81.6%, p<0.01), and 2-year (85.4 vs 79.9%, p<0.01) survival compared to recipients of other ages. However, in the BTT subgroup, recipients ≥70 (n=43) had similar 90-day (91.2 vs 84.7%, p=0.2), 1-year (86.1 vs 81.7%, p=0.4), and 2-year (82.8 vs 81.7%, p=0.6) survival compared to recipients of other ages (n=3,200). After adjusting for multiple recipient and donor factors, age ≥70 was still not associated with an increased hazard of mortality at 90-days, 1-year, or 2-years. These results were verified by analysis of a propensity-matched cohort. CONCLUSIONS-Although patients over the age of 70 years undergoing OHT have decreased survival, amongst patients bridged to heart transplantation, septuagenarians have similar outcomes as younger recipients. In carefully selected, LVAD-dependent patients, recipient age ≥70 should not be viewed as a contraindication to OHT.