Abstract
Purpose: In patients with end-stage heart failure the survival benefit of mechanical circulatory support with LVAD exceeds outcomes of any known medical therapy. With improved outcomes of LVAD implantation, increasing number of patients outlive the life-span of the LVAD, rendering the need for repeated surgeries which is challenging both for the LVAD team as well as the patient. Methods and Materials: We retrospectively reviewed indications and outcomes of device exchange among 188 pts with end-stage heart failure who received LVADs as a bridge-to-transplant (BTT, n 167) or destination therapy (DT, n 21) at the University of Minnesota between 1995 and 2006. One-way repeated measures ANOVA and Kaplan Meier estimates were employed for statistical analysis. Results: 17 pts (9.6%) required device replacement after a median device support time of 19 months. A total number of 44 permanent LVADs were placed in these patients; 7 patients received 3 devices. Indication for device exchange included pump failure (Heartmate, n 22), infected LVAD (Heartmate, n 2), refractory pump thrombosis (MicroMed DeBakey, n 3). Recipients of DT were most likely to undergo VAD exchange; 90% of them required at least one VAD replacement within 2 years (RR 3.5, p 0.01). There was no difference seen between the type of the first device inserted and the likelihood of VAD exchange: HM-IP (0/20 replacements), HM-VE (7/44 replacements), HM-XVE (7/82 replacements), HMII (0/25), and Micromed (3/8). Actuarial survival by Kaplan Meier analysis from the time of 1 implantation was 85.1% and 70.1% at 1 and 2 years respectively. Conclusions: With increasing reliability and durability of newer LVADs the need for LVAD pump exchanges may reduce in frequency. However, there will always be a select group of patients that will present with indications for and may benefit from LVAD pump exchange. Our study shows that with careful patient selection, peri-operative optimization and excellent surgical techniques, LVAD pump exchange is not only feasible, but also associated with good mid-term survival.
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