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In Vitro Thrombosis Test for Ventricular Assist Devices
Published on: March 21, 2025
Impact of Bridge to Transplantation With Continuous-Flow Left Ventricular Assist Devices on Posttransplantation
Lauren K Truby1, Maryjane A Farr2, A Reshad Garan2
1Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (L.K.T.).
Insights
Patients bridged to heart transplantation (HT) with a left ventricular assist device (LVAD) face higher early mortality risks. Careful consideration of transplant eligibility is crucial for these mechanically supported patients.
Area of Science:
- Cardiology
- Transplantation Medicine
- Mechanical Circulatory Support
Background:
- Bridge to transplantation (BTT) using left ventricular assist devices (LVADs) is a critical therapy for end-stage heart failure patients awaiting heart transplantation (HT).
- Current HT listing criteria do not differentiate between medically managed and mechanically bridged patients.
- This study investigates the impact of LVAD-supported BTT on post-HT survival and mortality risk factors.
Purpose of the Study:
- To evaluate the effect of BTT with LVAD on post-heart transplantation survival rates.
- To compare the causes of 1-year mortality between medically managed and mechanically bridged HT recipients.
- To identify risk factors associated with 1-year mortality in patients with and without LVAD at the time of HT.
Main Methods:
- Utilized the United Network of Organ Sharing database to analyze 5486 adult, single-organ HT recipients from 2008-2015.
- Employed propensity matching to account for the likelihood of LVAD use at HT.
- Kaplan-Meier survival analysis and logistic regression assessed 1- and 5-year mortality and odds ratios for risk factors.
Main Results:
- Mechanically bridged patients exhibited higher early mortality (9.5% at 1 year) compared to medically managed patients (7.2%).
- Increased 1-year mortality risk was observed in BTT patients with estimated glomerular filtration rates between 40-60 mL·min⁻¹·1.73 m⁻² and <40 mL·min⁻¹·1.73 m⁻².
- Higher body mass index (25-30 kg/m² and >30 kg/m²) also correlated with increased mortality risk in BTT patients.
Conclusions:
- While LVAD-supported BTT improves waitlist survival due to organ scarcity, it significantly increases early post-transplantation mortality risk.
- Patients bridged with mechanical support require meticulous evaluation for transplant eligibility post-LVAD implantation.
- Risk stratification, considering factors like age, renal function, and BMI, is essential for managing BTT patients.
Background:
Bridge to transplantation (BTT) with left ventricular assist devices (LVADs) is a mainstay of therapy for heart failure in patients awaiting heart transplantation (HT). Criteria for HT listing do not differ between patients medically managed and those mechanically bridged to HT. The objectives of the present study were to evaluate the impact of BTT with LVAD on posttransplantation survival, to describe differences in causes of 1-year mortality in medically and mechanically bridged patients, and to evaluate differences in risk factors for 1-year mortality between those with and those without LVAD at the time of HT.
Methods:
Using the United Network of Organ Sharing database, we identified 5486 adult, single-organ HT recipients transplanted between 2008 and 2015. Patients were propensity matched for likelihood of LVAD at the time of HT. Kaplan-Meier survival estimates were used to assess the impact of BTT on 1- and 5-year mortality. Logistic regression analysis was used to evaluate the odds ratio of 1-year mortality for patients BTT with LVAD compared with those with medical management across clinically significant variables at various thresholds.
Results:
Early mortality was higher in mechanically bridged patients: 9.5% versus 7.2% mortality at 1 year (P<0.001). BTT patients incurred an increased risk of 1-year mortality with an estimated glomerular filtration rate of 40 to 60 mL·min-1·1.73 m-2 (odds ratio, 1.69; P=0.003) and <40 mL·min-1·1.73 m-2 (odds ratio, 2.16; P=0.005). A similar trend was seen in patients with a body mass index of 25 to 30 kg/m2 (odds ratio, 1.88; P=0.024) and >30 kg/m2 (odds ratio, 2.11; P<0.001). When patients were stratified by BTT status and the presence of risk factors, including age >60 years, estimated glomerular filtration rate <40 mL·min-1·1.73 m-2, and body mass index >30 kg/m2, there were significant differences in 1-year mortality between medium- and high-risk medically and mechanically bridged patients, with 1-year mortality in high-risk BTT patients at 17.6% compared with 10.4% in high-risk medically managed patients.
Conclusions:
Bridge to HT with LVAD, although necessary because of organ scarcity and capable of improving wait list survival, confers a significantly higher risk of early posttransplantation mortality. Patients bridged with mechanical support may require more careful consideration for transplant eligibility after LVAD placement.
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