Nicholas G. Smedira, Katherine J. Hoercher, Jing Feng, Gonzalo Gonzalez-Stawinski, Randall C. Starling, Eugene H. Blackstone; Cleveland Clinic, Cleveland, OH
Objective: Among patients bridged to heart transplant (Tx) with mechanical circulatory support (MCS), Tx early after initiating MCS is said to increase mortality. Thus for many years the recommendation has been to delay Tx until a patient is rehabilitated and organ function recovers. Risk is counterbalanced by adverse events (AE) that increase with each day on MCS. Therefore, we investigated the total impact of MCS duration and AE on survival.Methods: At a single center from 1991 to July 2006, MCS was used as a bridge to TX in 374 patients , of whom 245 have undergone TX. Implantable pulsatile devices were used in 321, continuous flow in 13, TAH in 6, external pulsatile in 34. Two time-related models were developed: 1) a competing risk multivariable model of death on MCS or before Tx and 2) a model of death after TX in which patient factors and cumulative AEs on MCS were investigated as risk factors.
Results: Survival on MCS before Tx was 83%, 38%, and 17% at 1, 12, and 24 months. AE (neurological, pump pocket infection, reoperation for bleeding, and gastrointestinal complications) accumulated rapidly with duration of MCS (Fig 1). Overall survival after Tx was 94%, 88%, and 85% at 1, 12, and 24 months. Risk factors included longer but not shorter duration of MCS and occurrence of AEs (Fig 2).
Conclusion: Continued risk of dying on MCS and after Tx increases with longer duration of MCS and with occurrence of AEs. Thus there is an increased risk for each day on MCS and patients should undergo Tx as soon as a donor heart becomes available, whether or not organ function has recovered. This strategy represents a paradigm shift in current opinion but we believe will better utilize a scarce resource and eliminate the occurrence of salvage Tx.
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