Pre-Transplant Mechanical Ventilation Impacts Post-Transplant Survival in Infants at the Same Rate, with or without Ventricular Assist Devices

Abstract

<h3>Purpose</h3> Usage of ventricular assist devices (VADs) as a bridge to heart transplant (HT) in infants has been increasing over the past decade. Mechanical ventilation (MV) is a known risk factor for poor post-transplant survival (PTS), but it may be considered disproportionately when listing patients with or without VAD. This study sought to examine the effect of MV at HT in infants with or without VAD. <h3>Methods</h3> The United Network for Organ Sharing (UNOS) was queried for infants (<1 year) listed for HT (2006-2020). Cohort was divided into VAD & no-VAD. Effect of MV on PTS was examined between and within the 2 cohorts. Renal (estimated glomerular filtration rate <60 mL/min) and hepatic (bilirubin >1.2 mg/dL) dysfunction at HT were examined in intubated VAD infants. PTS was determined with Kaplan-Meier method. <h3>Results</h3> A total of 2856 patients were identified, 456 (15.9%) on VAD. Median waitlist time for VAD was 65 [32-120.5] vs 53 [21-111] days in no-VAD patients, p=0.001. A total of 320 (69.7%) VAD patients reached HT vs 1430 (59.5%) no-VAD. At HT, 25.6% (n=82) VAD patients were intubated compared to 32.9% (n=471) in no-VAD. Intubated VAD vs no-VAD patients had similar survival (p=0.3). Intubated patients had worse survival than non-intubated patients at a similar rate within the VAD & no-VAD groups (p=0.009 & p<0.001, respectively) (Figure). Although insignificant, the 1-yr survival of VAD infants intubated with renal dysfunction (n=23) was 58% vs 81% for those with normal function (n=59; p=0.2). Same trend was seen in intubated VAD infants with (n=21) or without (n=60) hepatic dysfunction (1-yr survival: 64% vs 77%, p=0.3). <h3>Conclusion</h3> MV decreases the post-HT survival in VAD and no-VAD infants at the same rate. Infants on VAD who are ventilated with renal or hepatic dysfunction at time of HT have a worse short-term survival than intubated VAD infants without these risk factors. Improvement in renal and/or hepatic function can improve survival of VAD patients.