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Niamat J, Ramjankhan F, Van Der Kaaij N, Gianoli M, Van Laake LW, Mokhles MM. Outcome after left ventricular assist device exchange. Eur J Cardiothorac Surg 2024; 66:ezae317. [PMID: 39235928 PMCID: PMC11486500 DOI: 10.1093/ejcts/ezae317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/17/2024] [Accepted: 09/03/2024] [Indexed: 09/07/2024] Open
Abstract
OBJECTIVES Left ventricular assist device (LVAD) therapy has evolved from a short-term bridge-to-transplant strategy into a long-term and often chronic therapy due to long waiting times for heart transplantation and application as destination therapy. Consequently, patients are at risk of developing complications necessitating LVAD exchange. The aim of this study is to assess patient outcomes after LVAD exchange. METHODS Patients who underwent LVAD exchange between January 2010 and December 2022 were included. Logistic and cox regression analyses were used to identify potential risk factors for short and long-term adverse events, respectively. Survival after exchange was assessed using Kaplan-Meier estimates. RESULTS Sixty-one patients underwent a total of 80 LVAD exchanges. Most frequently observed short-term complications were pulmonary infections (16.3%) and right heart failure (16.3%). Exit-site infections (34.7%) and device malfunctions (25.3%) were the most often observed long-term complications. HeartWare ventricular assist device as index device was associated with a higher risk of right heart failure [hazard ratio 6.42, 95% confidence interval (CI) 1.80-22.90] and respiratory failure (hazard ratio 7.81, 95% CI 1.95-31.23) compared to HeartMate II and HeartMate 3. Survival was 83% (95% CI 75.5-95.3%) at 1 year and 67% (95% CI 53.9-84.7%) at 6 years after exchange. After 5 years, 25.0% was transplanted, 23.8% had undergone a re-exchange and 32.5% was alive without new intervention. CONCLUSIONS Although LVAD exchange can be performed with a relatively low mortality, other post-operative adverse events are common. Patients with the HeartWare ventricular assist device as index device may be at higher risk of developing right heart failure and respiratory failure after exchange.
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Affiliation(s)
- Jaiel Niamat
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Faiz Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Niels Van Der Kaaij
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Monica Gianoli
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Linda W Van Laake
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
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Hullin R, Abdurashidova T, Pitta-Gros B, Schukraft S, Rancati V, Lu H, Zurbuchen A, Marcucci C, Ltaief Z, Lefol K, Huber C, Pascual M, Tozzi P, Meyer P, Kirsch M. Post-transplant survival with pre-transplant durable continuous-flow mechanical circulatory support in a Swiss cohort of heart transplant recipients. Swiss Med Wkly 2023; 153:3500. [PMID: 38579299 DOI: 10.57187/s.3500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Worldwide, almost half of all heart transplantation candidates arrive today at their transplant operation with durable continuous-flow mechanical circulatory support (CF-MCS). This evolution is due to a progressive increase of waiting list time and hence an increased risk of haemodynamic worsening. Longer duration of CF-MCS is associated with a higher risk of device-related complications with potential adverse impact on post-transplant outcome as suggested by recent results from the United Network of Organ Sharing of the United States. METHODS A 2-centre Swiss heart transplantation programme conducted a retrospective observational study of consecutive patients of theirs who underwent a transplant in the period 2008-2020. The primary aim was to determine whether post-transplant all-cause mortality is different between heart transplant recipients without or with pre-transplant CF-MCS. The secondary outcome was the acute cellular rejection score within the first year post-transplant. RESULTS The study participants had a median age of 54 years; 38/158 (24%) were females. 53/158 study participants (34%) had pre-transplant CF-MCS with a median treatment duration of 280 days. In heart transplant recipients with pre-transplant CF-MCS, the prevalence of ischaemic cardiomyopathy was higher (51 vs 32%; p = 0.013), the left ventricular ejection fraction was lower (20 vs 25; p = 0.047) and pulmonary vascular resistance was higher (2.3 vs 2.1 Wood Units; p = 0.047). Over the study period, the proportion of heart transplant recipients with pre-transplant CF-MCS and the duration of pre-transplant CF-MCS treatment increased (2008-2014 vs 2015-2020: 22% vs 45%, p = 0.009; increase of treatment days per year: 34.4 ± 11.2 days, p = 0.003; respectively). The primary and secondary outcomes were not different between heart transplant recipients with pre-transplant CF-MCS or direct heart transplantation (log-rank p = 0.515; 0.16 vs 0.14, respectively; p = 0.81). CONCLUSION This data indicates that the strategy of pre-transplant CF-MCS with subsequent orthotopic heart transplantation provides post-transplant outcomes not different to direct heart transplantation despite the fact that the duration of pre-transplant assist device treatment has progressively increased.
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Affiliation(s)
- Roger Hullin
- Cardiology, Cardiovascular Department, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Tamila Abdurashidova
- Cardiology, Cardiovascular Department, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Barbara Pitta-Gros
- Cardiology, Cardiovascular Department, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Sara Schukraft
- Cardiology, Cardiovascular Department, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Valentina Rancati
- Anesthesiology, Surgical Department, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Henri Lu
- Cardiology, Cardiovascular Department, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Anouck Zurbuchen
- Cardiology, Cardiovascular Department, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Carlo Marcucci
- Anesthesiology, Surgical Department, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Zied Ltaief
- Intensive Care Department, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Karl Lefol
- Solid Organ Transplantation Center, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Christoph Huber
- Cardiac Surgery, Cardiovascular Department, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Manuel Pascual
- Solid Organ Transplantation Center, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Piergiorgio Tozzi
- Cardiology, Department of Medical Specialties and Cardiovascular Surgery, Department of Surgery, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Philippe Meyer
- Cardiac Surgery, Cardiovascular Department, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Matthias Kirsch
- Cardiology, Department of Medical Specialties and Cardiovascular Surgery, Department of Surgery, Geneva University Hospital, University of Geneva, Geneva, Switzerland
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Badiwala M, Dvirnik N, Rao V. Durable mechanical circulatory support as bridge to heart transplantation. Curr Opin Organ Transplant 2022; 27:488-494. [PMID: 35950884 DOI: 10.1097/mot.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Durable mechanical circulatory support (MCS) technology has changed over time as devices have evolved from pulsatile to continuous flow support. In this review, we discuss recent data and substantial changes to current practice as it pertains to the subject of current era durable left ventricular assist devices (LVADs) as a bridge to heart transplantation. RECENT FINDINGS The results of heart transplantation in patients bridged with durable LVAD support are satisfactory even after prolonged duration of support. Reports of recent experience with LVAD related infection suggest that this complication has limited impact on post-transplant outcomes. Important sex-related disparities continue to exist following durable LVAD implantation. Recent changes in the United Network for Organ Sharing donor heart allocation policy have resulted in a drastic decline in the use of durable LVAD support for Bridge to Transplant in the United States. SUMMARY Durable MCS in the form of LVAD as a BTT strategy continues to evolve over time. Optimization of its role in the treatment of end-stage heart failure, particularly in females will need to be the focus of future research.
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Affiliation(s)
- Mitesh Badiwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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Left Ventricular Assist Device Exchange Increases Heart Transplant Wait-List Mortality. J Surg Res 2020; 255:277-284. [PMID: 32570131 DOI: 10.1016/j.jss.2020.05.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/02/2020] [Accepted: 05/03/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND The new heart transplant allocation criteria prioritize inpatients who require temporary mechanical circulatory support and give lower urgency to candidates on a durable left ventricular assist device (LVAD) who require a device exchange. This study explores whether the latter group should warrant higher priority to reduce wait-list mortality. METHODS This is a retrospective observational study of 13,113 adult heart transplant candidates in the Organ Procurement and Transplantation Network database who underwent LVAD implantation between 2007 and 2017. It evaluates the impact of LVAD exchange on the composite endpoint of death or removal from the wait list owing to worsening medical condition 1 y after device implantation. RESULTS There were 1085 pump exchanges in 954 patients (7% of candidates), of which 22% were women. The pump exchange rate was 5.92 events per 100 patient-years. One-year survival was lower for those who required a pump exchange (76.3% versus 88.5%, logrank P < 0.001). This was congruent with the risk-adjusted mortality 1-y after implantation (hazards ratio: 2.56, 95% confidence interval: 2.18-3.00, P < 0.001). CONCLUSIONS These findings indicate that among candidates awaiting heart transplantation with a durable LVAD, undergoing pump exchange doubles the risk of 1-y mortality. Giving priority to these candidates may reduce wait-list mortality.
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