Intra-Aortic Balloon Pump Bridging to Heart Transplantation

Abstract

Background: This study evaluates the impact of the 2018 allocation policy change on outcomes of orthotopic heart transplantation (OHT) in patients bridged with intra-aortic balloon pumps (IABPs). Methods: Adult (≥18 years) patients undergoing OHT between 2013 and 2019 who were bridged with an IABP were stratified based on temporal relation to the policy change. Univariate analysis was used to compare baseline characteristics and postoperative outcomes. Multivariate Cox regression analysis was used to estimate risk-adjusted predictors of post-transplant mortality. Results: A total of 1342 (8.6%) OHT patients were bridged with an IABP during the study period. Rates of bridging with IABP to OHT increased significantly after the policy change (7.0% versus 24.9%, P <0.001). The mean recipient age was 54.1±12.1 years with 981 (73.1%) patients being male. Baseline characteristics were similar between the 2 groups whereas post–policy change patients spent fewer days on the waitlist (15 versus 35 days, P <0.001), had longer ischemic times (3.5 versus 3.0 hours, P <0.001), and received organs from a greater distance (301 versus 105 miles, P <0.001). By multivariable analysis, days on the waitlist (for every 30 days; odds ratio, 1.01 [95% CI, 1.00–1.02], P =0.031) and diabetes mellitus (odds ratio, 1.87 [95% CI, 1.16–3.02], P =0.011) emerged as significant predictors of post-transplant mortality. After the policy change, waitlisted patients requiring IABP support were more likely to survive to transplant (76.4 versus 89.8%, P <0.001). Conclusions: IABP utilization has increased over 3-fold since the 2018 policy change with improved waitlist outcomes and comparable post-OHT survival. Thus, bridging patients to OHT with IABPs appears to be an effective strategy in the current era.

Increased frequency of heart transplantation, shortened waitlist time and preserved post‐transplant survival in adults with congenital heart disease, on the new heart transplant allocation system

“…The use of IABP has been reported as an effective bridge to transplant strategy in the new system. 23 Our results suggest that there was a shift in clinical practice, physicians who faced the choice of stabilizing an ACHD patient may have preferred to use an IABP. This would allow for a higher status, with broader organ availability, thus significantly increasing the chances of transplantation.…”

“…The choice of IABP to support a patient listed for heart transplantation will not only stabilize the patient but will also immediately increase the priority level in the transplant list (status 2). The use of IABP has been reported as an effective bridge to transplant strategy in the new system 23 . Our results suggest that there was a shift in clinical practice, physicians who faced the choice of stabilizing an ACHD patient may have preferred to use an IABP.…”

Impact of the new heart allocation policy on patients with restrictive, hypertrophic, or congenital cardiomyopathies

“…Third, we found that whereas the majority of patients were listed at Status 4, most were Status 2 at time of transplantation via use of intra-aortic balloon pumps (IABP), suggesting that this approach to improve prioritization for listing was being used rather than the standardized exceptions laid out by the OPTN (Organ Procurement and Transplantation Network) Review Board [13]. This indicates that centers might benefit from a greater consideration of the specific criteria for this patient population as a means to list at Status 2 urgency level when the clinical benefit from an IABP might be marginal.…”

Impact of mechanical circulatory support on donor heart allocation: past, present, and future

“…Patients who may be best served with LVAD therapy could be discouraged or prohibited from therapeutic options because of the comparatively lower urgency status it confers, and a disproportionately large number of patients offered higher-urgency temporary therapies such as ECMO. This trend forces patients to compete for organs based on clinical deterioration and creates incentives for physicians to withhold potentially life-saving treatment, a scenario akin to withholding dialysis treatment for a renal transplant candidate in clinical decline to optimize the candidate's likelihood of being matched to a donor [32]. In this scenario, the "life-boat" problem acknowledged with the previous system [33] will continue to burden transplant centers with more high-urgency candidates who are not being optimally managed, worsening patient outcomes and organ survival.…”