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J Thorac Cardiovasc Surg 2003;126:1188-1190
© 2003 The American Association for Thoracic Surgery

Brief communication

Does bridging to transplantation with a left ventricular assist device adversely affect posttransplantation survival? A comparative analysis of mechanical versus inotropic support

^a Department of Surgery, Division of Cardiothoracic Surgery, College of Physicians and Surgeons, Columbia University, New York, NY USA

Received for publication April 1, 2003; accepted for publication June 3, 2003.

^* Address for reprints: Yoshifumi Naka, MD, PhD, Columbia University, College of Physicians and Surgeons, 177 Fort Washington Ave, Milstein Hospital 7GN-435, New York, NY 10032, USA
yn33{at}columbia.edu

Implantation of a left ventricular assist device (LVAD) as a bridge to transplantation has become an acceptable intervention in patients with end-stage heart failure.^1,2 Patients bridged to transplantation with LVADs have demonstrated improvements in blood pressure, hepatic function, renal function, physical function, and quality of life.^3,4 However, whether mechanical support adversely affects posttransplantation survival is still controversial.⁵ Do patients bridged to transplantation with an LVAD demonstrate decreased posttransplantation survival compared with patients bridged with inotropic support? The aim of this study was to answer this question.

Patients and methods

We retrospectively reviewed our experience at Columbia Presbyterian Medical Center with bridge-to-transplantation patients from June 1996 through September 2002. During this time period, 266 patients in United Network for Organ Sharing status 1 were successfully bridged to transplantation by either mechanical (n = 121, 45.7%) or inotropic (n = 145, 54.5%) support. LVAD support was provided by the HeartMate single-lead vented electric device (Thoratec, Pleasanton, Calif). Posttransplantation survival at 1, 3, and 5 years was evaluated in both groups.

Data were represented as frequency distributions and percentages. Values of continuous variables were expressed as means ± SD. Continuous variables were compared by independent samples t tests, whereas categorical variables were compared by ² tests. Kaplan-Meier analysis was used to calculate survival. Actuarial survival at 1, 3, and 5 years after transplantation was calculated by constructing life tables. Significant risk factors for mortality were identified by multivariate Cox proportional hazard models. All data were analyzed with SPSS 11.5 software (SPSS Inc, Chicago, Ill).

Results

Demographics
Clinical demographics of patients in both groups are outlined in Table 1. Patients supported with LVADs were significantly younger than patients supported with inotropic therapy (48.7 ± 14.0 years vs 52.6 ± 13.6 years, P = .023). There were significantly more male patients in the LVAD group (85.1% vs 73.1%, P = .017). There was no significant difference in cause of heart failure between the groups.

View larger version (23K): [in this window] [in a new window]   Figure 1. Actuarial posttransplantation survival for patients supported with LVADs versus medical therapy.

On the basis of multivariate analysis with Cox proportional hazard models, female sex was the only variable demonstrated to be a statistically significant risk factor for decreased posttransplantation survival (odds ratio, 3.518; 95% confidence interval, 1.813-6.827; SE, 0.338; P < .001).

Discussion

In our study we demonstrated that patients bridged to transplantation with mechanical support had similar posttransplantation survival compared with that of United Network for Organ Sharing status 1 patients bridged with inotropic drugs. The HeartMate device, the first LVAD to gain US Food and Drug Administration approval for use as a bridge to transplantation, is the preferred device at our institution. It accommodates mobility, allowing patients to be discharged from the hospital and resulting in improved quality of life. It also obviates the need for anticoagulation.⁴

Limitations of this comparative study include that it was not a randomized study of LVAD versus inotropic therapy. LVADs were generally reserved for patients who had signs and symptoms of severe heart failure refractory to medical therapy. Therefore, patients supported with LVADs tended to manifest more severe clinical heart failure with a greater degree of instability than patients who were bridged to transplantation with inotropic drugs.

In conclusion, although the paradigm for assist devices might shift to a bridge to recovery or destination therapy, the role of an LVAD as a bridge to transplantation for patients with end-stage heart failure will remain an important one. At our institution, over the past 6 years, 71.2% (n = 121) of the 170 patients who underwent implantation of single-lead vented electric HeartMate devices as a bridge to transplantation were successfully bridged. LVADs permitted stabilization and optimization of patients with severe congestive heart failure without adversely affecting posttransplantation survival.³ A prospective randomized trial evaluating LVADs versus inotropic support for bridge-to-transplantation patients might be warranted to evaluate this issue more extensively.

References

1. Pennington DG, McBride LR, Peigh PS, Miller LW, Swartz MT. Eight years' experience with bridging to cardiac transplantation. J Thorac Cardiovasc Surg. 1994;107:472–481[Abstract/Free Full Text]
   
2. Peterze B, Lonn U, Jansson K, Rutberg H, Casimir-Ahn H, Nylander E. Long-term follow-up of patients treated with an implantable left ventricular assist device as an extended bridge to heart transplantation. J Heart Lung Transplant. 2002;21:604–607[Medline]
   
3. Bank AJ, Mir SH, Nguyen DQ, Bolman RM 3rd, Shumway SJ, Miller LW, et al. Effects of left ventricular assist devices on outcomes in patients undergoing heart transplantation. Ann Thorac Surg. 2000;69:1369–1375[Abstract/Free Full Text]
   
4. Sun BC, Catanese KA, Spanier TB, Flannery MR, Gardocki MT, Marcus LS, et al. 100 long-term implantable left ventricular assist devices: the Columbia Presbyterian interim experience. Ann Thorac Surg. 1999;68:688–694[Abstract/Free Full Text]
   
5. Massad MG, McCarthy PM, Smedira NG, Cook DJ, Ratliff NB, Goormastic M, et al. Does successful bridging with the implantable left ventricular assist device affect cardiac transplantation outcome? J Thorac Cardiovasc Surg. 1996;112:1275–1283[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mehmet C. Oz Yoshifumi Naka Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Morgan, J. A. Articles by Naka, Y. Search for Related Content PubMed PubMed Citation Articles by Morgan, J. A. Articles by Naka, Y. Related Collections Transplantation - heart