C. Lui1, A. Suarez-Pierre1, X. Zhou1, T. C. Crawford1, C. D. Fraser1, K. Giuliano1, S. Hsu2, R. Higgins1, K. J. Zehr1, G. J. Whitman1, C. W. Choi1, A. Kilic1 1The Johns Hopkins University School Of Medicine,Division Of Cardiac Surgery,Baltimore, MD, USA 2The Johns Hopkins University School Of Medicine,Department Of Cardiology,Baltimore, MD, USA
Introduction:
While the use of LVADs as a bridge to heart transplantation has increased over the last two decades, the physiological changes associated with LVAD support are poorly understood. We aim to explore the effect of pre-transplant systemic and device related complications on post-transplant survival for patients bridged with LVADs.
Methods:
The United Network of Organ Sharing (UNOS) database was queried for all adult heart transplant recipients (age >=18) transplanted from April 1, 2015 to June 31, 2018. Patients were categorized into patients without LVAD support and those who were bridged to transplantation with a Heartmate II, Heartmate III or Heartware HVAD device. Device related complications were defined as thrombosis, device infection or device malfunction. Systemic complications were identified as a new dialysis need or ventilator dependence between the time of listing and transplantation, transfusion, or systemic infection requiring treatment with IV antibiotics within two weeks of transplantation.
Results:
4032 patients underwent OHT without bridging with an LVAD while 2131 required LVAD support prior to transplantation. LVAD patients had greater rates of preoperative systemic complications (52.66% vs. 22.79%, p<0.001) compared to patients who were not bridged with an LVAD. Kaplan Meier analysis revealed a significantly decreased one-year survival for patients who experienced a pre-transplant systemic complication (p<0.001), and this finding persisted in the population of LVAD patients bridged to transplantation despite a smaller sample size (p=0.041). Interestingly, preoperative device related complications had no effect on one-year post transplantation survival (p=0.83). These findings suggest that the impact of systemic complications outweighs the effect of device related complications on post-transplant one-year survival. Multivariate cox modeling was performed to control for potential confounders, after which systemic complications were found to impart a significantly increased risk of post-transplant mortality for LVAD patients (HR 1.42, p=0.039).
Conclusion:
Our study provides insight on the importance of pre-transplant systemic complications for LVAD patients bridged to transplantation, and supports the recent changes to the UNOS allocation system for heart transplantation. These findings may help direct clinical management of LVAD patients waiting for a heart and assist in identifying at-risk recipients.
