The Impact of Bridge to Transplant VAD Support on Long Term Survival Following Cardiac Transplantation: Analysis of a Single Center Experience with over 1000 Heart Transplants
*David A Bull, *Craig H Selzman, Amit N Patel, Reza Khodaverdian, Dale G Renlund, *John A Hawkins
University of Utah Health Sciences, Salt Lake City, UT
BACKGROUND: Cardiac transplantation remains the gold standard for the treatment of end-stage heart failure. The major factor limiting the number of heart transplants done in the United States today is the availability of donor hearts. Ventricular assist devices (VAD) allow for the successful bridging of patients who otherwise would not be expected to survive long enough to receive a heart transplant. Several studies have reported equivalent survival at one year in patients who were bridged with a VAD as compared to the broader heart transplant population. Significantly less information is available, however, regarding the long term survival following cardiac transplantation in patients who underwent placement of a VAD as a bridge to transplant. We sought to examine our experience with the use of VADs as a bridge to cardiac transplantation to determine their potential impact on long term survival following cardiac transplantation.
METHODS: From 1985 to 2008, 1008 cardiac transplants were performed at a regional transplant center in the Western United States. Among these 1008 cardiac transplants, VADs were placed as a bridge to transplant in 112 patients. Data including gender, age, UNOS status, prior cardiac surgery, etiology of heart failure, prior placement of a ventricular assist device, panel reactive antibody (PRA) sensitization and Kaplan-Meier survival probabilities were analyzed using multivariable and shared frailty Cox regression models. Hazard Ratios (HR) and Confidence Intervals (CI) were calculated for each variable with a p value < 0.05 determined to be statistically significant.
RESULTS: For the entire cardiac transplant program, Kaplan-Meier survival probability at 1, 5, 10, 15 years was 87%, 79%, 41% and 24% respectively. At one year follow-up, there was no difference in survival between patients who had received VADs as a bridge to transplant and the general cardiac transplant population. At 5 and 10 years following cardiac transplantation, however, survival was significantly decreased in patients who had received a VAD as a bridge to transplant. Specifically, at 5 years survival was decreased to 45% (HR=2.37, CI 1.58-3.55, p<0.001) while at 10 years survival was decreased to 16% (HR=2.20, CI 1.55-3.13, p<0.001). Patients receiving VADs as a bridge to transplant were significantly more likely to have a PRA > 10% than the general pre-cardiac transplant population. In patients who received a VAD as a bridge to a cardiac transplant, elevation in the pre-transplant PRA correlated with a decrease in long term survival.
CONCLUSIONS: Placement of a VAD as a bridge to a cardiac transplant is associated with a decrease in long term survival following cardiac transplantation. This decrease in survival, however, is not manifest until 5 years following cardiac transplantation. The presence of an elevated PRA prior to transplantation may identify patients who are at greater risk of decreased long term survival following successful bridging to a cardiac transplant with placement of a ventricular assist device.
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