Assessing Consequences of Intraaortic Balloon Counterpulsation Versus Left Ventricular Assist Devices at the Time of Heart Transplantation

Abstract

The proportion of heart transplant recipients bridged with durable left ventricular assist devices (dLVADs) has dramatically increased; however, concern exists regarding obligate repeat sternotomy, increase bleeding risk due to anticoagulation and acquired von Willebrand disease, and increased rates of allosensitization. Whether dLVAD patients have impaired post-transplant outcomes compared to equivalent patients with less invasive intraaortic balloon counterpulsation (IABP) at the time of transplant is unknown. We therefore analyzed adult, first time, heart-only transplant procedures with dLVAD (n=2,636) compared to IABP (n=571) at the time of transplant based on data from the United Network for Organ Sharing (UNOS) 07/2004 – 12/2011. There was clear geographic variation in IABP and dLVAD at transplant. Multivariable analysis demonstrated equivalent cumulative risk of death (adjusted Cox proportional hazard ratio: 1.08, 95% confidence interval: 0.87 – 1.33, p=0.51). There was no significant difference in adjusted comparison of perioperative morality, length of stay, postoperative renal failure requiring dialysis, or early acute rejection (p≥0.14 for all). Data from UNOS therefore suggests that the presence of dLVAD at the time of heart transplantation does not have a detrimental effect on postoperative outcomes compared to IABP, which must be considered in the context of pre-transplant mortality and locoregional organ availability.

The Axillary Intra-Aortic Balloon Pump as a Bridge to Recovery Allows Early Ambulation in Long-Term Use

“…2 It has on the other hand been suggested that the IABP may be underused as a bridge to transplantation. 3 Clinical trials on acutely ill patients can be challenging, because the nuances of acute management cannot be captured through trial data points. For example, 10% of patients randomized to the control group in the IABP-SHOCK II trial received an IABP within days of randomization but were analyzed within that arm as intention to treat, which may falsely elevate survival rate.…”

Ambulatory Intra Aortic Balloon Pump in Advanced Heart Failure

“…19,20 However, LVADs have been shown to have similar perioperative mortality, length of hospital stay, renal failure requiring dialysis or early acute rejection compared to IABPs in patients undergoing heart transplant. 21 At the time of listing for transplant, patients who underwent IABP support (compared to LVAD) had significantly higher serum creatinine, lower BMI, lower proportion of blood type O and more functional impairment requiring full assistance with activities of daily living. 21 This study suggests that patients who have IABP support are generally more unwell and less mobile, which is likely to further exacerbate patient deconditioning.…”

“…21 At the time of listing for transplant, patients who underwent IABP support (compared to LVAD) had significantly higher serum creatinine, lower BMI, lower proportion of blood type O and more functional impairment requiring full assistance with activities of daily living. 21 This study suggests that patients who have IABP support are generally more unwell and less mobile, which is likely to further exacerbate patient deconditioning. Long-term IABP support has been shown to be effective as a bridge to LVAD implantation in critically ill end-stage CHF patients and was not associated with increased haemorrhagic complications.…”

Noteworthy Literature Published in 2017 for Thoracic Transplantation Anesthesiologists

“…Jennings et al 45 No increase in postoperative mortality after CTX. MCS as BTT Castleberry et al 47 No difference in outcomes between IABP vs LVAD support at time of CTX. Grimm et al 48 Duration of LVAD support did not predict mortality posttransplant.…”

“…Literature published in 2016 included 2 studies that addressed this issue. Castleberry et al 47 analyzed data from…”