During the last decade, the use of ventricular assist device (VAD) as bridge to transplant and bridge to candidacy has been steadily decreasing in the United States. Meanwhile implantation of durable VAD has nearly doubled from 41.2% to 78.1%. This shift in device strategy is due in part to a change in the listing status of the United Network of Organ Sharing (UNOS) in 2018 that has affected allocation of organs and clinical practice. The use of temporary mechanical circulatory support (e.g. intra-aortic balloon pump, extracorporeal membrane oxygenator (ECMO), temporary VAD) before transplant has in turn increased multifold. When considering the timing of VAD to transplant, one has to carefully weigh the benefits of patient optimization against the underlying risks and complications. Data from the Scientific Registry Transplant Recipients including over 30,000 patients provided insight into our understanding of three mortality phases (Early, Constant and Late) after heart transplant. Old age, high body mass index, congenital disease, organ (hepatobiliary and/or renal) dysfunction, ECMO, ventilation, and longer ischemic time, were identified as important risk factors for death. Interestingly, although women were more likely to be delisted or die after transplant, and were less likely to be transplanted, LVAD complications did not account for post-transplant adverse outcomes. Recent data suggested that decongestion and improvement of elevated pulmonary pressures (pulmonary vascular resistance) using LVAD before transplant was feasible and associated with similar survival rates as for patients who did not require VAD therapy. Compared with direct transplant, VAD bridge may be associated with reduced short-term (1-year) probability of death. Further research is needed to better understand the drivers of VAD complications that negatively impact survival after transplant. During the last decade, the use of ventricular assist device (VAD) as bridge to transplant and bridge to candidacy has been steadily decreasing in the United States. Meanwhile implantation of durable VAD has nearly doubled from 41.2% to 78.1%. This shift in device strategy is due in part to a change in the listing status of the United Network of Organ Sharing (UNOS) in 2018 that has affected allocation of organs and clinical practice. The use of temporary mechanical circulatory support (e.g. intra-aortic balloon pump, extracorporeal membrane oxygenator (ECMO), temporary VAD) before transplant has in turn increased multifold. When considering the timing of VAD to transplant, one has to carefully weigh the benefits of patient optimization against the underlying risks and complications. Data from the Scientific Registry Transplant Recipients including over 30,000 patients provided insight into our understanding of three mortality phases (Early, Constant and Late) after heart transplant. Old age, high body mass index, congenital disease, organ (hepatobiliary and/or renal) dysfunction, ECMO, ventilation, and longer ischemic time, were identified as important risk factors for death. Interestingly, although women were more likely to be delisted or die after transplant, and were less likely to be transplanted, LVAD complications did not account for post-transplant adverse outcomes. Recent data suggested that decongestion and improvement of elevated pulmonary pressures (pulmonary vascular resistance) using LVAD before transplant was feasible and associated with similar survival rates as for patients who did not require VAD therapy. Compared with direct transplant, VAD bridge may be associated with reduced short-term (1-year) probability of death. Further research is needed to better understand the drivers of VAD complications that negatively impact survival after transplant.
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Apr 1, 2024
J.M Safadi + 4
Open Access