Predictors of 30-day post-transplant mortality in patients bridged to transplantation with continuous-flow left ventricular assist devices—An analysis of the International Society for Heart and Lung Transplantation Transplant Registry

Abstract

Background Continuous-flow (CF) left ventricular assist devices (LVADs) are standard of care for bridging patients to cardiac transplantation. However, existing data about preoperative factors influencing early post-transplant survival in this population are limited. We sought to determine risk factors for mortality using a large international database. Methods All patients in the International Society for Heart and Lung Transplantation Transplant Registry who were bridged to transplantation with CF LVADs between June 2008 and June 2012 were included. Risk factors for mortality within 30 days of transplant were identified. Statistical approach included multivariable analysis and Kaplan-Meier survival analysis. Results During the study period, 2,152 CF LVAD patients underwent heart transplantation. Post-transplant survival was 95.5% at 30 days. Risk factors for mortality during this window included ventilator support at transplant (HR 5.00, 95% CI 1.51–16.58), female recipient/male donor (compared to male recipient/male donor, HR 3.29, 95% CI 1.90–5.72), history of hemodialysis (HR 2.51, 95% CI 1.14–5.51), and history of coronary bypass grafting (HR 1.89, 95% CI 1.19–3.00). Increasing recipient age (p=0.002), body mass index (p=0.002), creatinine (p=0.004), and total bilirubin (p<0.001) were also associated with an increase in mortality. Conclusions In patients supported with CF LVADs, risk factors for early mortality can be identified pre-transplant, including ventilator support, female recipient/male donor, and increasing recipient age and body mass index. Despite the inherent complexities of reoperative surgery, patients bridged to transplant with CF LVADs have excellent perioperative survival.

The Impact of Obesity on Patients Bridged to Transplantation With Continuous-Flow Left Ventricular Assist Devices

“…Next, the probability of transplantation decreases as BMI increases. And lastly, despite similar survival while on LVAD support, obese patients have worse post-transplant survival, consistent with the data from the ISHLT registry (3). …”

“…Obesity is a risk factor for heart failure and despite the “obesity paradox” where obese patients with heart failure have better outcomes than those of a normal BMI (1), many proceed to Stage D heart failure. Morbid obesity (BMI>35) is a barrier to candidacy for heart transplantation (HT) (2) and those who are obese and undergo transplantation have worse outcomes following HT (3). For these patients options include destination continuous-flow left ventricular assist device (LVAD), palliative care, weight loss, or a bridge to decision (weight loss) LVAD.…”

Variables of importance in the Scientific Registry of Transplant Recipients database predictive of heart transplant waitlist mortality

“…11 Among candidates bridged to transplant with VADs, factors affecting post-transplant survival included sex, mechanical ventilation, history of hemodialysis, history of coronary artery bypass surgery, serum creatinine, and serum bilirubin obtained around the time of transplantation. 34 In fact, death is often the result of many factors, making it imperative that we use statistical methods like RSF to handle complex interactions and to create allocation scores.…”

Early Outcomes After Heart Transplantation in Recipients Bridged With a HeartMate 3 Device

“…Although this study did not identify any differences in 6month survival across different devices, other predictors of mortality found in this analysis are consistent with those described in the literature. Incremental age [12] and MELD-XI score [13] have previously been demonstrated to correlate with early mortality. The MELD-XI is particularly useful to characterize BTT patients, who are chronically anticoagulated and have therapeutic International Normalized Ratio levels, hence rendering the traditional MELD score invalid.…”