Impact of long term left ventricular assist device therapy on donor allocation in cardiac transplantation

Abstract

Objective To study the effect of organ allocation system in the era of continuous flow pumps. Background Left Ventricular Assist Devices (LVAD) are increasingly used as a bridge to transplant (BTT) for patients with advanced congestive heart failure (CHF) and are assigned United Network for Organ Sharing (UNOS) high priority status (1B or 1A). Methods A retrospective chart review was performed of all patients transplanted between 1/2001–1/2011 at Columbia University Medical Center. Results 726 adult heart transplantations were performed. 274 BTT patients were implanted with LVAD; of which 227 patients were transplanted. 63 patients were transplanted as UNOS-1B, while 164 were transplanted as UNOS-1A (72%). Of these 164 patients, 65 were transplanted during their 30-day 1A period (43%) and 96 after upgrading to UNOS-1A for device complication (56%). For 452 non-device patients 139 (31%) were transplanted as UNOS-1A, 233 as UNOS-1B (52%), and 80 as UNOS-2 (17%). The percentage of patients bridged with LVAD increased from 19% in 2001 to 64% in 2010 while the number transplanted during their 30 day 1A grace period declined from 57% in 2005 to 16% in 2011; i.e. 84% of BTT patients in 2011 needed more than 30 days 1A time to be transplanted. Most LVAD patients are now transplanted while suffering device complication. There was no difference in post transplant survival between LVAD patients transplanted as UNOS 1B, 1A grace period or for a device complication Conclusions As wait time for cardiac transplantation increased the percentage of patients being bridged to transplant with an LVAD has increased with the majority of them transplanted in the setting of device complication.

Wearable Cardioverter-Defibrillator Therapy for the Prevention of Sudden Cardiac Death

“…Unfortunately, wait times for patients listed for transplantation can be highly variable and generally long and, in the era of mechanical circulatory support, have grown progressively longer for patients not at status 1A. 76,77 Therefore, unless patients are expected to remain in status 1A or are at status 1B in an organ procurement region with relatively short wait times (ie, <90 days), permanent ICD implantation has generally been the approach of choice, which is consistent with the International Society for Heart and Lung Transplantation guidelines for the care of cardiac transplantation candidates. 61 A permanent ICD is also preferred when the patient meets the criteria for cardiac resynchronization therapy.…”

“…Therefore, the general approach has been to pair LVAD therapy with permanent ICD therapy. For patients with bridge-to-transplantation LVAD who are listed at status 1A and have favorable blood type and low panel reactive antibodies, 77 WCD therapy may be an option. However, whether the efficacy of WCDs in the setting of LVAD equipment is altered remains poorly characterized.…”

Kidney Dysfunction and Left Ventricular Assist Device Support: A Comprehensive Perioperative Review

“…The decision to implant LVADs is complex and based on patient comorbidities, estimation of the waiting time to heart transplantation for bridge-to-transplantation candidates, estimation of reversibility of end-organ dysfunction, specifically kidney dysfunction, and assessment of psychosocial factors [8,9]. Greater experience related to patient selection and operative and perioperative LVAD management has led to an improved understanding of the effects of continuous flow physiology on kidney function.…”

Institutional Volume of Heart Transplantation with Left Ventricular Assist Device Explantation Influences Graft Survival

“…Additionally, specific LVAD variables such as LVAD-related complications, duration of LVAD support, and LVAD-related operative characteristics may be associated with posttransplant graft survival; however these data are not reliably available in the SRTR database. Uriel et al recently demonstrated that LVAD complications leading to higher priority UNOS listing status was not associated with post-transplant survival (11). Finally, our analyses included patients with pulsatile or continuous flow LVADs, however was adjusted for device type.…”