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Durable left ventricular assist device in donation after circulatory death heart transplantation
Yeahwa Hong1, Umar Nasim2, Nidhi Iyanna3
1Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA.
Insights
Donation after circulatory death (DCD) heart transplants in patients with durable left ventricular assist devices (LVADs) show lower survival. However, outcomes improve with higher acuity and specific devices, proving DCD transplants are safe for LVAD patients.
Area of Science:
- Cardiology
- Transplantation Medicine
- Medical Devices
Background:
- Donation after circulatory death (DCD) heart transplantation is an evolving field.
- Left ventricular assist devices (LVADs) are crucial for end-stage heart failure management.
- Evaluating DCD heart transplant outcomes in LVAD recipients is essential for optimizing patient care.
Purpose of the Study:
- To assess the survival rates of DCD heart transplant recipients who utilized a durable left ventricular assist device (LVAD) as a bridge to transplantation.
- To compare outcomes between DCD heart transplant recipients with and without durable LVAD support.
- To identify factors influencing post-transplant survival in this specific patient cohort.
Main Methods:
- Analysis of the UNOS registry for adult isolated DCD heart transplant recipients from January 2019 to March 2023.
- Stratification of recipients based on durable LVAD use prior to transplantation.
- Evaluation of 1-year post-transplant survival, with subgroup analyses for transplant status, device type, and donor type.
Main Results:
- Out of 703 recipients, 219 (31.2%) used a durable LVAD. These patients had significantly lower 1-year survival (88.4%) compared to non-LVAD recipients (93.6%, p=0.017).
- Among LVAD recipients, Status 4 patients showed improved survival. HeartMate II and III devices were associated with better outcomes than HeartWare HVAD.
- DCD and donation after brain death (DBD) recipients with LVADs demonstrated comparable 1-year survival rates (88.4% vs. 89.0%, p=0.763).
Conclusions:
- Durable LVAD use as a bridge to DCD heart transplantation is associated with reduced early post-transplant survival.
- Clinical acuity and LVAD device type significantly impact outcomes in DCD heart transplant recipients.
- DCD heart transplantation can be safely performed in durable LVAD candidates, achieving survival rates similar to DBD heart transplantation.
Background:
This study evaluates outcomes following donation after circulatory death (DCD) heart transplantation in recipients with a durable left ventricular assist device (LVAD).
Methods:
The UNOS registry was queried to analyze adult recipients of isolated DCD heart transplantation between 1/1/2019-3/31/2023. The recipients were stratified by durable LVAD use as a bridge to transplantation. The primary outcome was 1-year post-transplant survival. Sub-group analyses were conducted to evaluate the effects of transplant status, device type, and donor type on 1-year survival.
Results:
A total of 703 recipients were included, of which 219 (31.2%) recipients were bridged with a durable LVAD. The recipients of DCD hearts with durable LVADs had significantly lower 1-year post-transplant survival compared to those without durable LVADs (88.4% vs. 93.6%, p=0.017). Among the recipients bridged with durable LVADs, status 4 recipients had significantly improved 1-year survival compared to statuses 2 and 3 recipients, similar to those without durable LVADs. Furthermore, the recipients with HeartMate II and HeartMate 3 had improved survival compared to those with the HeartWare HVAD, similar to those without durable LVADs. Lastly, the DCD and DBD recipients with durable LVADs had comparable 1-year survival (88.4% vs. 89.0%, p=0.763).
Conclusions:
Recipients of DCD hearts bridged to transplantation with a durable LVAD exhibit reduced early post-transplant survival compared to those without a durable LVAD. However, clinical acuity and device type significantly influence post-transplant outcomes in this vulnerable population. Despite this, candidates with a durable LVAD can safely undergo DCD heart transplantation, achieving early post-transplant survival comparable to those of DBD heart transplantation.
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