Should patients 60 years and older undergo bridge to transplantation with continuous-flow left ventricular assist devices?

Although left ventricular assist devices (LVADs) are now commonly used as a bridge to orthotopic heart transplantation (OHT), the upper patient age limit for this therapy has not been defined. Smaller studies have suggested that advanced age should not be a contraindication to bridge to transplantation (BTT) LVAD placement. The purpose of this study was to examine outcomes in patients 60 years and older undergoing BTT with continuous-flow LVADs. The United Network for Organ Sharing (UNOS) database was reviewed to identify first-time OHT recipients 60 years of age and older (2005-2010). Patients were stratified by preoperative support: continuous-flow LVAD, intravenous inotropic agents, and direct transplantation. Survival after OHT was modeled using the Kaplan-Meier method. All-cause mortality was examined using multivariable Cox proportional hazard regression. Of 2,554 patients, 1,142 (44.7%) underwent direct transplantation, 264 (10.3%) had LVAD BTT, and 1,148 (45.0%) had BTT with inotropic agents. The mean age was 64±3 years, and 460 (18.0%) patients were women. Mean follow-up was 29±19 months. Survival differed significantly among the 3 groups. Patients with LVAD BTT had significantly lower survival after OHT compared with the other groups at 30 days and 1 year. This survival difference was no longer significant at 2 years after OHT or when deaths in the first 30 days were censored. LVAD BTT increased the hazard of death at 1 year by 50% (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.05-2.15; p=0.03), compared with patients who underwent direct transplantation. This study represents the largest modern cohort in which survival after OHT has been evaluated in patients 60 years or older who received BTT. Older patients have lower short-term survival after OHT when BTT is carried out with a continuous-flow LVAD compared with inotropic agents or direct transplantation.

Allen JG ，Kilic A ，Weiss ES ，Arnaoutakis GJ ，George TJ ，Shah AS ，Conte JV ... -  《-》

Outcomes in patients older than 60 years of age undergoing orthotopic heart transplantation: an analysis of the UNOS database.

Weiss ES ，Nwakanma LU ，Patel ND ，Yuh DD ... -  《-》

Post-cardiac transplant survival after support with a continuous-flow left ventricular assist device: impact of duration of left ventricular assist device support and other variables.

John R ，Pagani FD ，Naka Y ，Boyle A ，Conte JV ，Russell SD ，Klodell CT ，Milano CA ，Rogers J ，Farrar DJ ，Frazier OH ... -  《-》

Improved survival and decreasing incidence of adverse events with the HeartMate II left ventricular assist device as bridge-to-transplant therapy.

Pulsatile left ventricular assist devices (LVADs) are effective as bridge-to-transplant therapy, but they are limited by their large size and lack of durability. Smaller, more durable, continuous flow devices such as the HeartMate II LVAD are increasingly being used. The aim of this study is to report our single-center experience with this device as bridge-to-transplant therapy. Overall, 47 patients received HeartMate II LVADs at our center from June 2005 to July 2007; 32 as bridge to transplant, 7 as destination therapy, and 8 as exchange therapy for a failed HeartMate XVE. We reviewed our experience with the device as bridge-to-transplant therapy and report on patient survival and adverse events. The mean age of the bridge-to-transplant patients was 50.75 +/- 13.78 years; 10 (31.3%) were female. The cause of the underlying disease was ischemic in 18 patients (56.3%), idiopathic in 11 (34.4%), myocarditis in 1 (3.1%), postpartum cardiomyopathy in 1 (3.1%), and congenital heart disease in 1 (3.1%). The mean duration of HeartMate II support was 193.2 +/- 139.9 days. At 30 days after HeartMate II placement, the patient survival was 96.9% by Kaplan-Meier analysis; at 6 months (alive or transplanted), 86.9%. Major adverse events included bleeding requiring reexploration in 5 patients (15.6%), right ventricular failure requiring right ventricular assist device support in 2 (6.3%), LVAD-related infections in 4 (12.5%), neurologic or thromboembolic events in 2 (6.3%), and gastrointestinal bleeding in 5 (15.6%). We noted one serious device malfunction (3.1%) resulting in the patient's death; in addition, 2 patients experienced pump thrombosis (6.3%). Despite morbidity, use of the HeartMate II LVAD as bridge-to-transplant therapy is associated with excellent survival and low mortality rates. We found a marked decrease in morbidity related to right ventricular failure, to device-related infections, and to thromboembolic events. However, the requirements for anticoagulation therapy may be associated with increased mediastinal and gastrointestinal bleeding. Strategies to optimize anticoagulation therapy may further improve results for these critically ill patients.

John R ，Kamdar F ，Liao K ，Colvin-Adams M ，Boyle A ，Joyce L ... -  《-》

Postcardiac transplant survival in the current era in patients receiving continuous-flow left ventricular assist devices.

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 post-transplant 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. 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. 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 ± 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 ± 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 = 62) compared with those who had received a left ventricular assist device later (2009-2011, n = 78, 373 vs 392 days, P = 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 = 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. The short- and long-term post-transplant survival for patients bridged with a continuous-flow left ventricular assist device in the current era has been excellent. Furthermore, the duration of left ventricular assist device support did not affect post-transplant survival. The hemodynamic benefits of ventricular unloading with continuous-flow left ventricular assist devices, in addition to their durability and reduced patient morbidity, have contributed to improved post-transplant survival.

Kamdar F ，John R ，Eckman P ，Colvin-Adams M ，Shumway SJ ，Liao K ... -  《-》