The Effect of Ventricular Assist Devices on Post-Transplant Mortality (original) (raw)
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Ventricular Assist Devices as a Bridge to Cardiac Transplantation: The Ottawa Experience
Artificial Organs, 2004
This article reports our experience with ventricular assist devices (VADs) as a bridge to cardiac transplantation. From 1991 to 2003, a total of 42 patients received a Thoratec VAD (Thoratec Laboratories Corporation Inc., Pleasanton, CA, U.S.A.) (Group T) and 12 patients received a Novacor VAD (WorldHeart Corporation, Ottawa, Canada) (Group N). Thirty Thoratec patients were transplanted compared to six in the Novacor group. Four more Novacor patients are still supported. Of the transplanted patients, 87% survived to hospital discharge in Group T and 67% in Group N. Infections affected 29% and 50% of Group T patients during support and post-transplantation, respectively, compared to 25% and 0%, respectively, in Group N. Neurologic complications affected 33% of patients in each group during support. Reopening rates for bleeding during support were 45% and 42% in Groups T and N, respectively. There were no significant differences in outcomes between the two groups. Our study demonstrated the effectiveness of VADs in bridging mortally ill cardiac patients to successful heart transplantation.
2010
This study sought to determine the relationship between pre-transplant ventricular assist device (VAD) support and mortality after heart transplantation. Background Increasingly, VADs are being used to bridge patients to heart transplantation. The effect of these devices on post-transplant mortality is unclear. Methods Patients 18 years or older who underwent first-time, single-organ heart transplantation in the U.S. between 1995 and 2004 were included in the analyses. This study compared 1,433 patients bridged with intracorporeal and 448 patients bridged with extracorporeal VADs with 9,455 United Network for Organ Sharing status 1 patients not bridged with a VAD with respect to post-transplant mortality. Because the proportional hazards assumption was not met, hazard ratios (HRs) for different time periods were estimated. Results Intracorporeal VADs were associated with an HR of 1.20 (95% confidence interval [CI]: 1.02 to 1.43; p ϭ 0.03) for mortality in the first 6 months after transplant and an HR of 1.99 (95% CI: 1.44 to 2.75; p Ͻ 0.0001) beyond 5 years. Between 6 months and 5 years, the HRs were not significantly different from 1. Extracorporeal VADs were associated with an HR of 1.91 (95% CI: 1.53 to 2.37; p Ͻ 0.0001) for mortality in the first 6 months and an HR of 2.93 (95% CI: 1.19 to 7.25; p ϭ 0.02) beyond 5 years. The HRs were not significantly different from 1 between 6 months and 5 years, except for an HR of 0.23 (95% CI: 0.06 to 0.91; p ϭ 0.04) between 24 and 36 months. Conclusions Extracorporeal VADs are associated with higher mortality within 6 months and again beyond 5 years after transplantation. Intracorporeal VADs are associated with a small increase in mortality in the first 6 months and a clinically significant increase in mortality beyond 5 years. These data do not provide evidence supporting VAD implantation in stable United Network for Organ Sharing status I patients awaiting heart transplantation.
The Journal of Heart and Lung Transplantation, 2010
Purpose: The CardioWest temporary total artificial heart (TAH-t; SynCardia, Inc, Tucson, AZ) has been approved and successfully implemented as a temporary device for bridge to cardiac transplantation. After hospitalization and convalescence in a reahilitation center, patients with CardioWest-t in Europe may be discharged from hospital to a home setting, while waiting for a donor organ. We present our single-center experience with outpatient management and follow-up of CardioWest-t recipients. Methods and Materials: Between 01/2006 and 09/2009 a total of 48 patients received CardioWest-t TAH for treatment of biventricular heart failure in our institution. Nineteen of the 48 recipients were discharged from hospital on Berlin Heart portable CardioWest-t driver. Demographic parameters and causes of clinical readmissions and death were retrospectively analyzed. Results: Median age of CardioWest-t recipients was 52 years (27-72); two of them were female. Median support duration in outpatients was 428 days (range 76-723). Six of the 19 patients were successfully bridged to heart transplantation with median waiting time of 455 days (221-669). There were 8 readmissions due to infection (in 5 cases related to device), 6 due to bleeding (in 3 cases requiring surgery), 3 related to cerebro-vascular accident and 9 others. Ten patients died on the device. Major cause of death were mediastinitis (nϭ3) and sepsis related cerebro-vascular accident (nϭ3). Four other patients died on support due to bleeding requiring surgery (nϭ1), multiorgan failure (nϭ2) and pump-stop due to patient error (nϭ1). Conclusions: Support with Cardiowest-t TAH may allow patients with terminal biventricular heart failure to be discharged home and reintegrated into family life. Ambulatory follow-up of these VAD patients may significantly decrease hospital costs and provides safe bridge to heart transplantation or transplantability.
Transplantation Proceedings, 2019
Background. Continuous flow left ventricular assist devices (CF-LVAD) are widely used as a bridge to transplantation (BTT) among patients with advanced heart failure. The primary outcome of the current study was to study the incidence of waitlist mortality and morbidity of CF-LVAD patients bridged to heart transplantation in the current BTT era and to determine the factors that increased their risk of delisting. Methods. Patients who were bridged to heart transplant with a CF-LVAD between April 2008 and September 2015 were identified from the United Network for Organ Sharing heart transplant registry. They were then categorized based on the development of complications. Cox proportional hazards and Kaplan-Meier survival curves were used for time-to-event analysis for the primary outcome. Results. Out of 7070 patients who were bridged to heart transplant, 2510 (36%) developed device-related complications. The primary outcome was present in 1631 of 7070 patients (23%). Independent predictors of primary outcome were age, ABO blood group, etiology of cardiomyopathy, and history of diabetes mellitus. Developing one device-related complication was associated with a hazard ratio (HR) of 2.59 of having the primary outcome. The HR increased to 3.45 when !2 of the defined complications occurred. In patients who developed the primary outcome, they most likely had a device infection (odds ratio 2.51). Conclusion. Findings from the current study add to the existing literature about the incidence of morbidity and mortality in the current BTT era. Development of one devicerelated complication increases the risk of death or delisting among patients on the heart transplant waitlist; however, this risk almost doubles when 2 or more complications occur.
The Journal of Thoracic and Cardiovascular Surgery, 2013
Objectives: Continuous-flow left ventricular assist devices have become the standard of care for patients with heart failure requiring mechanical circulatory support as a bridge to transplant. However, data on long-term posttransplant survival for these patients are limited. We evaluated the effect of continuous-flow left ventricular assist devices on postcardiac transplant survival in the current era. Methods: All patients who received a continuous-flow left ventricular assist device as a bridge to transplant at a single center from June 2005 to September 2011 were evaluated. Results: Of the 167 patients who received a continuous-flow left ventricular assist device as a bridge to transplant, 77 (46%) underwent cardiac transplantation, 27 died before transplantation (16%), and 63 (38%) remain listed for transplantation and continued with left ventricular assist device support. The mean age of the transplanted patients was 54.5 AE 11.9 years, 57% had an ischemic etiology, and 20% were women. The overall mean duration of left ventricular assist device support before transplantation was 310 AE 227 days (range, 67-1230 days). The mean duration of left ventricular assist device support did not change in patients who had received a left ventricular assist device in the early period of the study (2005-2008, n ¼ 62) compared with those who had received a left ventricular assist device later (2009-2011, n ¼ 78, 373 vs 392 days, P ¼ NS). In addition, no difference was seen in survival between those patients supported with a left ventricular assist device for fewer than 180 days or longer than 180 days before transplantation (P ¼ NS). The actuarial survival after transplantation at 30 days and 1, 3, and 5 years by Kaplan-Meier analysis was 98.7%, 93.0%, 91.1%, and 88.0%, respectively.