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Published on: July 18, 2014
Optimal Timing of Heart Transplant After HeartMate II Left Ventricular Assist Device Implantation
Robert J Steffen1, Eugene H Blackstone2, Nicholas G Smedira1
1Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Insights
Optimal heart transplantation timing for patients on a continuous-flow left ventricular assist device (LVAD) is within 9 months. Delaying transplantation beyond this period decreases survival rates, especially for those with preoperative risk factors.
Area of Science:
- Cardiovascular Surgery
- Transplantation Medicine
- Medical Device Engineering
Background:
- The optimal timing for heart transplantation in patients supported by second-generation left ventricular assist devices (LVADs) remains unclear.
- Despite this uncertainty, LVAD patients receive priority on the heart transplant waiting list.
- This study aimed to define the ideal timing for transplantation in patients bridged with continuous-flow LVADs.
Purpose of the Study:
- To determine the optimal time for heart transplantation in patients receiving continuous-flow left ventricular assist device (LVAD) support.
- To analyze the impact of LVAD support duration on post-transplant survival.
- To identify preoperative risk factors influencing survival on LVAD support and after transplantation.
Main Methods:
- Analysis of 301 HeartMate II LVAD implantations in 285 patients between October 2004 and June 2013.
- Evaluation of 86 patients who underwent heart transplantation during the follow-up period.
- Calculation of optimal transplantation timing based on survival during LVAD support and post-transplant survival.
Main Results:
- Three-year survival was comparable whether transplantation occurred within 9 months of LVAD implantation.
- Survival decreased significantly when LVAD support exceeded 9 months.
- Preoperative risk factors (e.g., prior cardiac surgery, low albumin, renal dysfunction) and complications (e.g., device issues, intracranial hemorrhage) negatively impacted survival.
Conclusions:
- Patient survival on HeartMate II support is influenced by preoperative comorbidities and postoperative complications.
- Transplantation should be performed before the onset of complications to maximize patient survival.
- Early transplantation, ideally within 9 months of LVAD support, is crucial for optimizing outcomes.
Background:
Optimal timing of heart transplantation in patients supported with second-generation left ventricular assist devices (LVADs) is unknown. Despite this, patients with LVADs continue to receive priority on the heart transplant waiting list. Our objective was to determine the optimal timing of transplantation for patients bridged with continuous-flow LVADs.
Methods:
A total of 301 HeartMate II LVADs (Thoratec Corp, Pleasanton, CA) were implanted in 285 patients from October 2004 to June 2013, and 86 patients underwent transplantation through the end of follow-up. Optimal transplantation timing was the product of surviving on LVAD support and surviving transplant.
Results:
Three-year survival after both HeartMate II implantation and heart transplantation was unchanged when transplantation occurred within 9 months of implantation. Survival decreased as the duration of support exceeded this. Preoperative risk factors for death on HeartMate II support were prior valve operation, prior coronary artery bypass grafting, low albumin, low glomerular filtration rate, higher mean arterial pressure, hypertension, and earlier date of implant. Survival for patients without these risk factors was lowest when transplant was performed within 3 months but was relatively constant with increased duration of support. Longer duration of support was associated with poorer survival for patients with many of these risk factors. Device reimplantation, intracranial hemorrhage, and postimplant dialysis during HeartMate II support were associated with decreased survival.
Conclusions:
Survival of patients supported by the HeartMate II is affected by preoperative comorbidities and postoperative complications. Transplantation before complications is imperative in optimizing survival.
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