Changes in Use of Left Ventricular Assist Devices as Bridge to Transplantation With New Heart Allocation Policy

Mullan, Clancy; Chouairi, Fouad; Sen, Sounok; Mori, Makoto; Clark, Katherine; Reinhardt, Samuel W.; Miller, Paul E.; Fuery, Michael; Jacoby, Daniel; Maulion, Christopher; Anwer, Muhammad; Geirsson, Arnar; Mulligan, David C.; Formica, Richard N.; Rogers, Joseph G.; Desai, Nihar R.; Ahmad, Tariq

doi:10.1016/j.jchf.2021.01.010

Cited by 88 publications

(96 citation statements)

References 13 publications

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“…In our analysis, the 360 days post‐transplant survival did not achieve statistical significance between the old and new systems. Our results contrast with a recent publication reporting a significant increase in post‐transplant mortality in the LVAD‐BTT population in the new HT allocations system 10 . The discordant results are likely due to differences in the study design (selected cohorts, inclusion criteria, follow‐up time, among other).Prior studies analyzing the survival in the overall transplant population in the new HT allocation system have also reported conflicting results, with some describing worse survival 19 while others described similar survival with the new system 20,29–32 .…”

Section: Discussioncontrasting

confidence: 99%

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Decreased frequency of transplantation and lower post‐transplant survival free of re‐transplantation in LVAD patients with the new heart transplant allocation system

Jani

Lee

Acharya

et al. 2021

Clinical Transplantation

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Purpose:To evaluate the effect of the new heart transplant (HT) allocation system in left ventricular assist device (LVAD) supported patients listed as bridge to transplantation (BTT).Methods: Adult patients who were listed for HT between October 18, 2016 and October 17, 2019, and were supported with an LVAD, enrolled in the UNOS database were included in this study. Patients were classified in the old or new system if they were listed or transplanted before or after October 18, 2018, respectively.Results: A total of 3261 LVAD patients were listed for transplant. Of these, 2257 were classified in the old and 1004 in the new system. The cumulative incidence of death or removal from the transplant list due to worsening clinical status at 360-days after listing was lower in the new system (4% vs. 7%, P = .011). LVAD Patients listed in the new system had a lower frequency of transplantation within 360-days of listing (52% vs. 61%, P < .001). A total of 1843 LVAD patients were transplanted, 1004 patients in the old system and 839 patients in the new system. The post-transplant survival at 360 days was similar between old and new systems (92.3% vs. 90%, P = .08). However, LVAD patients transplanted in the new system had lower frequency of the combined endpoint, freedom of death or re-transplantation at 360 days (92.2% vs. 89.6%, P = .046). Conclusion:The new HT allocation system has affected the LVAD-BTT population significantly. On the waitlist, LVAD patients have a decreased cumulative frequency of transplantation and a concomitant decrease in death or delisting due to worsening status. In the new system, LVAD patients have a decreased survival free of retransplantation at 360 days post-transplant.

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Section: Discussioncontrasting

confidence: 99%

“…A recent publication reported unchanged outcomes in the waitlist and worse post‐transplant survival on the LVAD population with the new allocation system; however, insufficient follow‐up could account for some of the reported findings 10 …”

Section: Introductionmentioning

confidence: 97%

Decreased frequency of transplantation and lower post‐transplant survival free of re‐transplantation in LVAD patients with the new heart transplant allocation system

Jani

Lee

Acharya

et al. 2021

Clinical Transplantation

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“…Current guidelines and position papers recommend anticoagulation with vitamin K antagonist for all patients on LVAD support targeting INR levels of 2-2.5 in most institutions (in others 2-3) and low-dose aspirin. 6,33 Long-term anticoagulation is tailored to the recipient and device type.…”

Section: Anticoagulationmentioning

confidence: 99%

Guidance on the management of left ventricular assist device (LVAD) supported patients for the non‐LVAD specialist healthcare provider: executive summary

Gal

Avraham

Miličić

et al. 2021

European J of Heart Fail

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The accepted use of left ventricular assist device (LVAD) technology as a good alternative for the treatment of patients with advanced heart failure together with the improved survival of patients on the device and the scarcity of donor hearts has significantly increased the population of LVAD supported patients. Device-related, and patient-device interaction complications impose a significant burden on the medical system exceeding the capacity of LVAD implanting centres. The probability of an LVAD supported patient presenting with medical emergency to a local ambulance team, emergency department medical team and internal or surgical wards in a non-LVAD implanting centre is increasing. The purpose of this paper is to supply the immediate tools needed by the non-LVAD specialized physician -ambulance clinicians, emergency ward physicians, general cardiologists, and internists -to comply with the medical needs of this fast-growing population of LVAD supported patients. The different issues discussed will follow the patient's pathway from the ambulance to the emergency department, and from the emergency department to the internal or surgical wards and eventually back to the general practitioner.

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“…An unintended consequence of the change in allocation system has been the shift in practice to utilize temporary, rather than durable, MCS to support candidates on the waitlist. HTx recipients with pre-HTx implanted left ventricular assist devices (LVADs) decreased from 41.8% to 21.2% [11], and candidates receiving LVADs while on the waitlist decreased from 14.5% to 10.8% [16]. Concurrently, there has been an increase in candidates on temporary MCS from 11.3% to 22.9% [11,16].…”

Section: New Allocation Systemmentioning

confidence: 99%

“…HTx recipients with pre-HTx implanted left ventricular assist devices (LVADs) decreased from 41.8% to 21.2% [11], and candidates receiving LVADs while on the waitlist decreased from 14.5% to 10.8% [16]. Concurrently, there has been an increase in candidates on temporary MCS from 11.3% to 22.9% [11,16]. In particular, use of IABP to bridge to HTx has increased from 7.6% to 26.2% [10,17], and bridging with Impella CP (Abiomed, Danvers, MA, USA) has also increased from 0.8% to 9.8% [18].…”

Section: New Allocation Systemmentioning

confidence: 99%

Current status and outcomes in heart transplantation: a narrative review

Awad¹,

Shah²,

Griffith³

2022

Rev. Cardiovasc. Med.

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The first human heart transplantation was performed by Christian Barnard in 1967. While the technical aspect had been worked out, allograft rejection was a major limitation in the early days of heart transplant. The discovery of cyclosporine revolutionized the field and led to the modern era of transplant. Heart transplantation now offers the best survival benefit for patients with end-stage heart failure with a median survival over 12 years. However, there are still limitations including the impact of limited availability of graft, graft dysfunction, and rejection, and long-term non-cardiac complications. This review serves as an update on the short-and long-term outcomes following heart transplantation focusing on the new donor allocation system, efforts to expand the donor pool, primary graft dysfunction, acute cellular and antibody-mediated rejection, cardiac allograft vasculopathy, and post-transplant malignancy and renal dysfunction.

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Changes in Use of Left Ventricular Assist Devices as Bridge to Transplantation With New Heart Allocation Policy

Cited by 88 publications

References 13 publications

Decreased frequency of transplantation and lower post‐transplant survival free of re‐transplantation in LVAD patients with the new heart transplant allocation system

Decreased frequency of transplantation and lower post‐transplant survival free of re‐transplantation in LVAD patients with the new heart transplant allocation system

Guidance on the management of left ventricular assist device (LVAD) supported patients for the non‐LVAD specialist healthcare provider: executive summary

Current status and outcomes in heart transplantation: a narrative review

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