Ventricular Assist Device Utilization in Heart Transplant Candidates: Nationwide Variability and Impact on Waitlist Outcomes. (April 2018)

• Record Type: Journal Article
• Authors: Truby, Lauren K.; Garan, A. Reshad; Givens, Raymond C.; Takeda, Koji; Takayama, Hiroo; Trinh, Pauline N.; Yuzefpolskaya, Melana; Farr, Maryjane A.; Naka, Yoshifumi; Colombo, Paolo C.; Topkara, Veli K.
• Is Part Of: Circulation. Volume 11:Number 4(2018)
• Publication Date: 2018-04
• Subjects: heart-assist devices -- heart transplantation -- propensity -- score -- registries -- waiting lists; Heart failure -- Periodicals; 616.129005
• DOI: 10.1161/CIRCHEARTFAILURE.117.004586
• Languages: English
• ISSNs: 1941-3289

Abstract

Abstract : Background: Continuous-flow left ventricular assist devices (CF-LVADs) have become a standard treatment choice in advanced heart failure patients. We hypothesized that practice patterns with regards to CF-LVAD utilization vary significantly among transplant centers and impact waitlist outcomes. Methods and Results: The United Network for Organ Sharing registry was queried to identify adult patients who were waitlisted for heart transplantation (HT) between 2008 and 2015. Each patient was assigned a propensity score based on likelihood of receiving a durable CF-LVAD before or while waitlisted. The primary outcomes of interest were death or delisting for worsening status and HT at 1 year. A total of 22 863 patients from 92 centers were identified. Among these, 9013 (39.4%) were mechanically supported. CF-LVAD utilization varied significantly between and within United Network for Organ Sharing regions. Freedom from waitlist death or delisting was significantly lower in propensity-score–matched patients who were mechanically supported versus medically managed (83.5% versus 79.2%; P <0.001). However, cumulative incidence of HT was also lower in mechanically supported patients (53.3% versus 63.6%; P <0.001). Congruous mechanical and medical bridging strategies based on clinical risk profile were associated with lower risk of death or delisting (hazard ratio, 0.88; P =0.027) and higher likelihood of HT (hazard ratio, 1.14; P <0.001). Conclusions: CF-LVAD utilization may lower waitlist mortality at the expense of lower likelihood of HT. Decision to use CF-LVAD and timing of transition should be individualized based on patient-, center-, and region-level risk factors to achieve optimal outcomes. Abstract : Supplemental Digital Content is available in the text.