Emerging roles of left ventricular assist device therapy as bridge to transplant in an Asian city with scarce heart transplant donor

Abstract

Background: Left ventricular assist device (LVAD) has been increasingly used in patients with advanced heart failure. This study aimed to assess the impact of implementation of LVAD therapy on heart transplantation (HTx) service in Hong Kong (HK). Methods: LVAD program was started in 2010 in HK and patients who had been put on HTx waiting list since the start of HTx program in HK from 1992 to 2020 were included for analysis. Survival on HTx waiting list between pre-LVAD era 1992-2009 and post-LVAD era 2010-2020 were analyzed by Kaplan-Meier method and compared by log-rank test. Multivariate analysis by time-dependent Cox-proportional hazard model was used to identify independent predictors of HTx waiting list mortality. Results: A total of 478 heart transplant listing episodes involving 457 patients were included for analysis.There were 232 heart transplantations (HTxs), including one re-transplantation, during the study period.There were 110 patients who received LVAD as bridge to transplantation (BTT) and 30 of them had undergone subsequent HTx. The 1-, 2-and 3-year survival on waiting list were 82.3%, 61.7% and 43.0% respectively in the pre-LVAD era (n=178), while the 1-, 2-and 3-year survival were significantly improved at 85.7%, 81.8% and 78% respectively in the post-LVAD era (n=300), (P=0.003). Time-dependent multivariate analysis revealed that LVAD support was independently associated with significant reduction of waiting list mortality [odds ratio (OR): 0.21; 95% confidence interval (CI): 0.10-0.44, P<0.001]. There was no significant difference when comparing survival after LVAD as BTT and survival after HTx up to 8 years (76.1% vs. 72% at 8 years respectively, P=0.732). Conclusions: Waiting list survival improved in the post-LVAD era driven by the implementation of LVAD service. Long-term survival for LVAD recipients as BTT were comparable to heart transplant recipients in HK.

Post-transplant survival with pre-transplant durable continuous-flow mechanical circulatory support in a Swiss cohort of heart transplant recipients

“…Today's clinical importance of pre-transplant CF-MCS is evident from various registries: the INTERMACS registry shows that almost 50% of all CF-MCS implantations are intended as either a bridge to transplant or a bridge to candidacy for heart transplantation [25]; the ISHLT registry documents that 42.9% of all heart transplantation recipients arrived at transplant surgery with pre-transplant MCS [4]; the United Network of Organ Sharing (UNOS) registry reported a proportion of 37.3% heart transplantation recipients with pre-transplant MCS [26]; European or Asian centres specify pre-transplant CF-MCS in 22% to 47% of their local heart transplantation recipient cohorts [27][28][29][30]. In accordance, the present cohort indicates pre-transplant CF-MCS in 33.5% of all heart transplantation recipients.…”

Trends in contemporary advanced heart failure management: an in-depth review over 30 years of heart transplant service in Hong Kong

“…Heart failure syndrome affects an estimated 38 million people worldwide, with a prevalence of 1% to 2% among adults [ 1 - 3 ]. Advanced heart failure (AHF) refers to heart failure that has progressed to a stage in which traditional evidence-based treatments have become ineffective and the patient has severe symptoms, frequent episodes of decompensation, and poor survival [ 3 - 5 ]. The incidence of AHF is increasing despite dramatic innovations in medical and device-based treatments for heart failure in recent decades [ 3 , 4 , 6 , 7 ].…”

“…The first HTx in Hong Kong (HK) was performed on December 18, 1992 [ 8 ], and the year 2022 marks the 30th anniversary of both the first HTx recipient and the HTx service in HK. Long-term outcomes after HTx in HK have been promising and are comparable to international benchmarks [ 5 ]. However, the disparity between available donor hearts and potential recipients on the HTx waiting list has continued to grow [ 5 ].…”

“…Long-term outcomes after HTx in HK have been promising and are comparable to international benchmarks [ 5 ]. However, the disparity between available donor hearts and potential recipients on the HTx waiting list has continued to grow [ 5 ]. As in the rest of the world, donor availability remains the major limitation for HTx service; on average, only 12 HTx have been performed annually in HK in recent years [ 5 ].…”

“…However, the disparity between available donor hearts and potential recipients on the HTx waiting list has continued to grow [ 5 ]. As in the rest of the world, donor availability remains the major limitation for HTx service; on average, only 12 HTx have been performed annually in HK in recent years [ 5 ]. Meanwhile, care for patients with AHF remains challenging and continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and dedicated efforts to improve patient-centered management programs.…”