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Optimal pretransplant duration with HeartMate III left ventricular assist device: A contemporary analysis
Ahmet Bilgili1, Iverson E Williams1, Omar M Sharaf1
1Division of Cardiovascular Surgery, Department of Surgery, University of Florida Health, Gainesville, Florida; Congenital Heart Center, Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida.
Insights
Longer use of HeartMate III (HM3) left ventricular assist device (LVAD) support before heart transplant is linked to worse survival. Bridging for over two years with an HM3 LVAD increases post-transplant mortality risk.
Area of Science:
- Cardiovascular Surgery
- Transplantation Medicine
- Mechanical Circulatory Support
Background:
- The HeartMate III (HM3) left ventricular assist device (LVAD) is increasingly used for bridging patients to heart transplantation.
- Understanding the impact of HM3 support duration on post-transplant outcomes is crucial for optimizing patient management.
Purpose of the Study:
- To evaluate the association between pretransplant HM3 LVAD support duration and post-heart transplant survival.
- To identify potential risk inflection points for HM3 support duration in heart transplant recipients.
Main Methods:
- Retrospective analysis of the United Network for Organ Sharing database (January 2019-December 2023).
- Included adult heart transplant recipients bridged with HM3 LVAD.
- Cox proportional hazards model with restricted cubic splines to stratify patients into support duration groups (<1, 1-2, >2 years) and compare outcomes.
Main Results:
- 1,996 patients were analyzed, with support durations distributed as <1 year (35.2%), 1-2 years (32.2%), and >2 years (32.7%).
- Postoperative stroke and acute rejection rates were similar across groups.
- Rates of postoperative dialysis increased significantly with longer support duration (p < 0.001).
- One-year survival was lower for patients bridged >2 years (84.3%) compared to <1 year (90.7%) (p < 0.001).
- Multivariable analysis showed increased hazard of post-transplant mortality for support durations of 1-2 years (HR: 1.34) and >2 years (HR: 1.77) compared to <1 year.
Conclusions:
- While the HM3 facilitates extended bridging to heart transplantation, support durations exceeding two years are associated with diminished post-transplant survival.
- Longer HM3 support duration is an independent risk factor for post-transplant mortality.
Background:
This study evaluates the impact of pretransplant HeartMate III (HM3) left ventricular assist device (LVAD) support duration on post-transplant survival in a contemporary cohort.
Methods:
A retrospective review of the United Network for Organ Sharing database was conducted for adult heart transplant recipients from January 2019 to December 2023 who were bridged with an HM3 LVAD. We utilized a restricted cubic spline fitted to a Cox proportional hazards model to stratify patients into duration groups based on risk inflection points (<1, 1-2, and >2 years), and outcomes were compared between and across groups.
Results:
Among 1,996 patients, 35.2% (n = 702), 32.2% (n = 642), and 32.7% (n = 652) had support durations of <1, 1 to 2, and >2 years, respectively. Median support duration was 518 days [interquartile range: 289-864]. Postoperative rates of stroke and acute rejection did not vary across groups (p > 0.05); however, rates of postoperative dialysis significantly increased with increasing support time (p > 0.001). One-year survival was significantly higher for patients bridged <1 year (90.7% [95% confidence interval: 88.5-93.0]) compared to those bridged >2 years (84.3% [95% CI: 81.4-87.4], p < 0.001) but not for those bridged 1 to 2 years (89.0% [95% CI: 86.6-91.6], p = 0.300). In multivariable analysis, patients supported 1 to 2 years (hazards ratio: 1.34 [1.01-1.79], p = 0.045) and >2 years (hazards ratio: 1.77 [1.32-2.38], p < 0.001) had a higher hazard of post-transplant mortality than those bridged <1 year.
Conclusions:
While the HM3 enables extended bridging to transplant, durations longer than 2 years of support are linked to worse post-transplant survival.
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