Competing Risks to Transplant in Bridging with Continuous Flow Left Ventricular Assist Devices.
Ann Thorac Surg 2021;
114:1276-1283. [PMID:
34808111 DOI:
10.1016/j.athoracsur.2021.09.079]
[Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 09/10/2021] [Accepted: 09/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND
Continuous flow left ventricular assist device(CF-LVAD) support is a mainstay in the hemodynamic management of patients with end-stage heart failure refractory to optimal medical therapy. In this report, we evaluated waitlist complications and competing outcomes for CF-LVAD patients compared to primary transplant candidates listed for orthotopic heart transplantation(OHT) at a single center.
METHODS
All patients listed for OHT between 2006-2020 at our institution were retrospectively reviewed(n=300 CF-LVAD; n=244 primary transplant). Kaplan-Meier methodology with log-rank testing was used to evaluate survival outcomes. Terminal outcomes of death, delisting, and transplant were assessed as competing risks and compared between groups using Gray's test. Multivariable Fine-Gray regression was used to identify predictors of transplantation.
RESULTS
One-year rates of transplant, delisting, and death were 48%, 8%, and 2%, respectively for CF-LVAD patients and 45%, 15%, and 9% for primary transplant(all P<0.001). Waitlist mortality at 5 years was 4% among CF-LVAD patients and 13% for primary transplants. All-cause mortality after listing was lower for CF-LVAD patients(P=0.017). There was no difference in post-transplant survival between groups(P=0.250). On multivariable Fine-Gray regression, stroke(P=0.017), respiratory failure(P=0.032), right ventricular failure(P=0.019), and driveline infection(P=0.050) were associated with decreased probability of transplantation. Post-transplant survival was not significantly worse for CF-LVAD patients who experienced device-related complications(P=0.901).
CONCLUSIONS
While device related-complications were significantly associated with decreased rates of transplant, CF-LVAD patients had excellent waitlist outcomes overall. In light of the 2018 allocation score change, the risk of complications should be taken into account when deciding whether to offer CF-LVAD as a bridge to transplant.
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