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. 2018 Apr;11(4):e004586.
doi: 10.1161/CIRCHEARTFAILURE.117.004586.

Ventricular Assist Device Utilization in Heart Transplant Candidates: Nationwide Variability and Impact on Waitlist Outcomes

Lauren K Truby  1 , A Reshad Garan  1 , Raymond C Givens  1 , Koji Takeda  1 , Hiroo Takayama  1 , Pauline N Trinh  1 , Melana Yuzefpolskaya  1 , Maryjane A Farr  1 , Yoshifumi Naka  1 , Paolo C Colombo  1 , Veli K Topkara  2
Affiliations

Ventricular Assist Device Utilization in Heart Transplant Candidates: Nationwide Variability and Impact on Waitlist Outcomes

Lauren K Truby et al. Circ Heart Fail. 2018 Apr.

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.

Keywords: heart transplantation; heart-assist devices; propensity; registries; score; waiting lists.

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Figures

Figure 1
Figure 1. Study Population
Figure 2
Figure 2. Nationwide Variability in Device Utilization in Heart Transplantation Candidates (A) Among UNOS Regions (B) Within UNOS Regions
Figure 3
Figure 3. Transplant Waitlist Outcomes of Patients with Medical versus Mechanical Bridging Strategy (A) Freedom from Waitlist Death or Delisting for Worsening Status (B) Cumulative Incidence of Heart Transplantation
Figure 4
Figure 4
Transplant Waitlist Outcomes of Patients Based on Congruous versus Incongruous Utilization of Bridging Strategies (A) Freedom from Waitlist Death or Delisting for Worsening Status Based (B) Cumulative Incidence of Heart Transplantation
See this image and copyright information in PMC

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