LVADs: The Western Australian Experience

Abstract

<h3>Purpose</h3> Review outcomes of the Western Australian (WA) LVAD program. <h3>Methods</h3> Retrospective review of medical records and local databases. <h3>Results</h3> In 23 years, 140 LVADs (no RVAD/BIVADs) have been inserted in WA: 46 HeartWare HVAD (HW), 26 HeartMate III (HM3), 16 HeartMate II (HM2), and 52 earlier generation devices. Abstract data refers to HW/HM2/HM3. Insertion indications were non-ischaemic cardiomyopathy (60%) and ischaemic (40%). 89% were inotrope dependant pre-implant, with median LV ejection fraction 20%. 34% had severe right ventricular (RV) dysfunction on echo, and on right heart catheterisation median cardiac index was 1.7L/min/m². We aggressively and pre-emptively manage for RV failure (RVF): early RVF (requirement for inotropes >14 days) occurred in only 7% and no patients required RVAD. 64% received ≥5 days of early inhaled pulmonary vasodilators, and 88% were discharged on sildenafil (median daily dose 150mg). Median ICU length of stay (LOS) was 2 days. 95% of patients survived to hospital discharge (median LOS 23 days). Following discharge, median percentage of days with LVAD spent as an outpatient was 98%, and median number of hospital readmissions was 1.8 per patient years. LVAD-associated infection requiring admission or intravenous antibiotics occurred in 36%, gastrointestinal bleeding in 16%, and stroke in 11%. The percentage of patients alive with LVAD at 1, 2, and 5 years was 93%, 87%, and 63%, respectively, which betters current international INTERMACS survival. 93% of patients were implanted as bridge-to-transplant/candidacy, with median transplant wait time 9 months. Of our six destination therapy patients there have been no deaths before 5 years, and our centre holds the world record for the 2 longest surviving HW patients at 11.3 and 10.5 years. All aspects of VAD management including anticoagulation and driveline care are performed exclusively by our service in Perth (the nearest VAD centre is 1700 miles away). <h3>Conclusion</h3> Excellent outcomes can be achieved with single-centre care despite geographical isolation.