Hospital transfer of patients for LVAD bridge to transplant: is timing really critical to success?

Abstract

Background: Implantable left ventricular devices (LVAD) as bridge to transplant (BTT) are used to salvage critically ill patients who would not survive without aggressive mechanical support. This strategy has resulted in the development of established referral patterns to experienced transplant centers with an emphasis on early transfer which is thought to be critical to successful outcomes. We reviewed our experience with patients transferred from outside hospitals in an effort to elucidate risk factors which may predict poor outcome. Methods: We retrospectively reviewed data on 202 patients who completed LVAD/BTT support between December 1991 and October 2000. Of those, 134 (66%) were transferred from outside hospitals (median stay5 5 days). In these 134 pts, indications for transfer included, 40% acute MI (28% , 3days, 12% 3-7days),13% post-cardiotomy, and 47% other. 7/134 pts were transferred on ECMO or Abiomed and 27/134 underwent ECMO placement at our institutuion (median time until placement 51 day). Median time from admission until LVAD support was 3 days. Results: Survival until transplant for these 134 pts was 68% with the median duration of support 79 days (range50-324). The patient group at highest risk for death on support were those transferred within 24 hours of their initial hospitalization (n538 pts) versus those transferred . 24 hrs( 47% vs 27%, p50.03). One explanation may be that this group represented a more critically ill population, including acute MI (61% vs 9% . 24 hrs, p50.0001), need for Abiomed or ECMO (47% vs 19% p50.001), and ischemic disease 91% vs 62% p50.002). Conclusion: Transfer of critically ill patients to undergo LVAD/ BTT is associated with an overall good survival, however, in a subset of patients who have severe hemodynamic compromise associated with acute MI, ischemia, and need for Ecmo or Abiomed, mortality is high despite the strategy of very early transfer (, 24 hrs)and intervention.