Strategies of Wait-listing for Heart Transplant vs Durable Mechanical Circulatory Support Alone for Patients With Advanced Heart Failure

Rowland, Jem J.; Ferket, Bart S.; Gelijns, Annetine C.; Bagiella, Emilia; Pinney, Sean; Moskowitz, Alan J.; Miller, Marissa A.; Pagani, Francis D.; Mancini, Donna

doi:10.1001/jamacardio.2020.0631

Cited by 29 publications

(18 citation statements)

References 31 publications

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“…4,5 VADs are currently implanted as bridge to transplantation (BTT) or destination therapy (DT). 1 However, limitations apply for both strategies, including driveline infections, device-related neurologic events, bleeding complications, and device malfunction. Although heart transplantation still delivers best long-term results, even this treatment option is far from curing the initial disease.…”

Section: Leora B Balsam MDmentioning

confidence: 99%

Ventricular assist device–promoted recovery and technical aspects of explant

Faerber

Doenst

2021

JTCVS Techniques

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Feature Editor Note-Promoting left ventricular recovery after durable left ventricular assist device (LVAD) implantation remains a Holy Grail. Currently, less than 2% of patients exhibit signs of recovery after LVAD implantation, and even fewer tolerate device explantation without recurrence of heart failure. In this issue of the Journal, Drs Faerber and Doenst describe what we can do clinically to promote recovery, including how guidelinedirected medical therapy may facilitate structural remodeling of the unloaded heart. Identifying recovery in the presence of ventricular unloading also presents a challenge, and the authors describe weaning protocols for various devices. Current evidence suggests that there are clinical predictors of recovery, including younger age, nonischemic etiology, smaller left ventricular size, and shorter duration from diagnosis of heart failure, and these can be used to help draw our focus toward patients who are more likely to tolerate device weaning and explantation. In those patients, preparing for device explantation requires early surgical planning, often at the time of LVAD implantation, including correction of valvular lesions that will be hemodynamically significant in the absence of LVAD support.

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Section: Leora B Balsam MDmentioning

confidence: 99%

Ventricular assist device–promoted recovery and technical aspects of explant

Faerber

Doenst

2021

JTCVS Techniques

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“…2 . Linked UNOS and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry data prior to HeartMate 3 LVAD (HM3) availability show superior survival for patients bridged to HT with an LVAD (BTT) than those receiving an LVAD as provisional destination therapy (DT) [ 3 ]. Survival after HM3 implantation in the MOMENTUM 3 trial was roughly 87% at 1 year and 79% at 2 years regardless of intent (BTT, DT, or bridge to candidacy) as compared to 90% and 85% one- and three-year post-HT survival, respectively [ 6 ].…”

Section: Heart Failure Disparities In the Current Landscape Of Advancmentioning

confidence: 99%

Are the current evaluation tools for advanced therapies biased?

Givens

2021

Current Opinion in Cardiology

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Purpose of review Despite attention to racial disparities in outcomes for heart failure (HF) and other chronic diseases, progress against these inequities has been gradual at best. The disparities of COVID-19 and police brutality have highlighted the pervasiveness of systemic racism in health outcomes. Whether racial bias impacts patient access to advanced HF therapies is unclear. Recent findings As documented in other settings, racial bias appears to operate in HF providers’ consideration of patients for advanced therapy. Multiple medical and psychosocial elements of the evaluation process are particularly vulnerable to bias. Summary Reducing gaps in access to advanced therapies will require commitments at multiple levels to reduce barriers to healthcare access, standardize clinical operations, research the determinants of patient success and increase diversity among providers and researchers. Progress is achievable but likely requires as disruptive and investment of immense resources as in the battle against COVID-19.

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“…Despite advances in long‐term mechanical circulatory support, heart transplant (HTx) remains the most valuable therapeutic option for patients with end‐stage heart failure 1‐3 . More than 5000 HTx procedures are performed each year worldwide, with a median posttransplant survival of greater than 12 years 4 .…”

Section: Introductionmentioning

confidence: 99%

Statistical performance of 16 posttransplant risk scores in a contemporary cohort of heart transplant recipients

Coutance

Kransdorf

Bonnet

et al. 2021

American Journal of Transplantation

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Accurate risk stratification of early heart transplant failure is required to avoid futile transplants and rationalize donor selection. We aimed to evaluate the statistical performance of existing risk scores on a contemporary cohort of heart transplant recipients. After an exhaustive search, we identified 16 relevant risk scores. From the UNOS database, we selected all first noncombined adult heart transplants performed between 2014 and 2017 for validation. The primary endpoint was death or retransplant during the first year posttransplant. For all scores, we analyzed their association with outcomes, sensitivity, specificity, likelihood ratios, and discrimination (concordance index and overlap of individual scores). The cohort included 9396 patients. All scores were significantly associated with the primary outcome (P < .001 for all scores). Their likelihood ratios, both negative and positive, were poor. The discriminative performance of all scores was limited, with concordance index ranging from 0.544 to 0.646 (median 0.594) and an important overlap of individual scores between patients with or without the primary endpoint. Subgroup analyses revealed important variation in discrimination according to donor age, recipient age, and the type of assist device used at transplant. Our findings raise concerns about the use of currently available scores in the clinical field.

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Strategies of Wait-listing for Heart Transplant vs Durable Mechanical Circulatory Support Alone for Patients With Advanced Heart Failure

Cited by 29 publications

References 31 publications

Ventricular assist device–promoted recovery and technical aspects of explant

Ventricular assist device–promoted recovery and technical aspects of explant

Are the current evaluation tools for advanced therapies biased?

Statistical performance of 16 posttransplant risk scores in a contemporary cohort of heart transplant recipients

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