Time to Reconsider Bridging Older Children on Outpatient Inotrope in an Era of Outpatient VADs

Abstract

<h3>Purpose</h3> Both ventricular assist devices (VADs) and inotropes are feasible modalities used to bridge children to heart transplant (HT) in the outpatient setting. However, it is unclear which modality, if either, yields superior functional status at time of HT and post-transplant survival (PTS). <h3>Methods</h3> The United Network for Organ Sharing (UNOS) database was used to identify patients (age ≤18 & >25 kg) who were listed for HT in 2012-2020 and were admitted from outpatient setting for HT. Patients were grouped as (a) inotrope only, (b) VAD only, (c) neither at HT. Primary outcome of interest included no-to-mild functional limitation at HT (Performance Scale >70%) and PTS. <h3>Results</h3> A total of 691 patients were included: 196 (28%) VAD-only, 168 (24%) inotrope only, 327 (47%) neither. Patients on VAD were heavier, more likely to be male, and more likely to have dilated cardiomyopathy than the other groups. Patients were more likely to be bridged on inotrope in the Midwest; conversely, they were more likely to be bridged on VAD in the West. Patients with VAD-only had superior functional status at HT (Table). Overall, PTS in VAD-only patients was comparable to patients with no support (p=0.266) and comparable to inotrope-only (p=0.279). VAD-only patients showed better 2-year conditional survival, compared to inotropes-only (p=0.05) (Figure). <h3>Conclusion</h3> As expected, short term outcomes for pediatric patients bridged to HT in the outpatient setting with VAD or inotropes is excellent. However, compared to outpatients bridged to HTx on inotropes, outpatient VAD support allowed for better clinical status at HT and superior long-term transplant survival.