Should Patients 60 Years and Older Undergo Bridge to Transplantation With Continuous-Flow Left Ventricular Assist Devices?

Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
The Annals of thoracic surgery (Impact Factor: 3.85). 08/2012; 94(6). DOI: 10.1016/j.athoracsur.2012.06.009
Source: PubMed


Although left ventricular assist devices (LVADs) are now commonly used as a bridge to orthotopic heart transplantation (OHT), the upper patient age limit for this therapy has not been defined. Smaller studies have suggested that advanced age should not be a contraindication to bridge to transplantation (BTT) LVAD placement. The purpose of this study was to examine outcomes in patients 60 years and older undergoing BTT with continuous-flow LVADs.

The United Network for Organ Sharing (UNOS) database was reviewed to identify first-time OHT recipients 60 years of age and older (2005-2010). Patients were stratified by preoperative support: continuous-flow LVAD, intravenous inotropic agents, and direct transplantation. Survival after OHT was modeled using the Kaplan-Meier method. All-cause mortality was examined using multivariable Cox proportional hazard regression.

Of 2,554 patients, 1,142 (44.7%) underwent direct transplantation, 264 (10.3%) had LVAD BTT, and 1,148 (45.0%) had BTT with inotropic agents. The mean age was 64±3 years, and 460 (18.0%) patients were women. Mean follow-up was 29±19 months. Survival differed significantly among the 3 groups. Patients with LVAD BTT had significantly lower survival after OHT compared with the other groups at 30 days and 1 year. This survival difference was no longer significant at 2 years after OHT or when deaths in the first 30 days were censored. LVAD BTT increased the hazard of death at 1 year by 50% (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.05-2.15; p=0.03), compared with patients who underwent direct transplantation.

This study represents the largest modern cohort in which survival after OHT has been evaluated in patients 60 years or older who received BTT. Older patients have lower short-term survival after OHT when BTT is carried out with a continuous-flow LVAD compared with inotropic agents or direct transplantation.

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    • "This finding is in agreement with Shiga et al.20 who showed age as an independent risk factor for death after pulsatile extracorporeal LVAD implantation. Additionally, patients 60 years and older were shown to have significantly poorer survival after the heart transplantation at 30 days and 1 year when previously bridged by the CF-LVAD compared to those bridged by inotropic support or transplanted directly.24 Therefore, patient’s age seems to play a crucial role in predicting early post-LVAD mortality suggesting appropriate selection of the patients for LVAD implantation as a bridge to transplantation. "
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    ABSTRACT: Left ventricular assist devices (LVADs) are fast becoming standard of care for patients with advanced heart failure. However, despite continuous improvement in VAD technology there remains a significant early post-operative morbidity and mortality in this extreme patient group. The aim of the present study was to explore the short-term outcomes and predictors for 90-day mortality in the patients after implantation of continuous flow LVAD.Peri-operative clinical, echocardiographic, hemodynamic and laboratory data of 90-day survivors and non-survivors were collected and compared retrospectively. Multivariate logistic regression analysis was performed on univariate predictors for 90-days mortality with an entry criterion of p<0.1.Between July, 2006 and May, 2012, 117 patients underwent implantation of a continuous flow LVAD as a bridge to transplantation: 71 (60.7%) HeartMate II (Thoratec Corp) and 46 (39.3%) HVAD (HeartWare International). All cause 90-day mortality was 17.1%. Multivariate analysis revealed higher preoperative CVP (OR 1.18, 95% CI 1.014-1.378; p=0.033) and higher age (OR 1.14, 95% CI 1.01-1.38; p=0.045) as the only independent predictors for 90-day mortality.Optimization of pre-operative volume status, preload and right heart function as well as age based selection of candidates for LVAD support are the critical factors influencing early outcome after continuous flow LVAD implantation.
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    ABSTRACT: Abstract End-stage heart failure is a major health problem, but implementation of guidelines and optimizing medical therapy for this devastating disease should decrease mortality. If optimal conservative therapy is no longer sufficient, a mechanical support system may be required as final destination therapy or as bridge-to-transplant. Since the first heart transplantation in 1967, this therapy has become the criterion standard for end-stage heart failure, but is limited due to organ shortage. Tissue engineering could help overcome this limitation and provide regeneration, remodeling, and growth potential. This so-called bio-artificial heart would be available, created by a decellularized extracellular matrix and seeded with in vitro proliferated autologous cardiovascular cells. Results of the first experimental studies have been promising, but numerous challenges must be met before this procedure will be available.
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