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CLINICAL RESEARCH: HEART FAILURE

The Effect of Ventricular Assist Devices on Post-Transplant Mortality

An Analysis of the United Network for Organ Sharing Thoracic Registry

Vishnu Patlolla, MD, MPH^_*, Richard D. Patten, MD, David DeNofrio, MD, Marvin A. Konstam, MD and Rajan Krishnamani, MD^,_*

^_* Department of Medicine, Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
Division of Cardiology, Tufts Medical Center, Boston, Massachusetts

Manuscript received April 29, 2008; revised manuscript received July 14, 2008, accepted August 18, 2008.

^_* Reprint requests and correspondence: Dr. Rajan Krishnamani, Division of Cardiology, Tufts Medical Center, 800 Washington Street, Box 5931, Boston, Massachusetts 02111 (Email: rkrishnamani{at}tuftsmedicalcenter.org).

Objectives: This study sought to determine the relationship between pre-transplant ventricular assist device (VAD) support and mortality after heart transplantation.

Background: Increasingly, VADs are being used to bridge patients to heart transplantation. The effect of these devices on post-transplant mortality is unclear.

Methods: Patients 18 years or older who underwent first-time, single-organ heart transplantation in the U.S. between 1995 and 2004 were included in the analyses. This study compared 1,433 patients bridged with intracorporeal and 448 patients bridged with extracorporeal VADs with 9,455 United Network for Organ Sharing status 1 patients not bridged with a VAD with respect to post-transplant mortality. Because the proportional hazards assumption was not met, hazard ratios (HRs) for different time periods were estimated.

Results: Intracorporeal VADs were associated with an HR of 1.20 (95% confidence interval [CI]: 1.02 to 1.43; p = 0.03) for mortality in the first 6 months after transplant and an HR of 1.99 (95% CI: 1.44 to 2.75; p < 0.0001) beyond 5 years. Between 6 months and 5 years, the HRs were not significantly different from 1. Extracorporeal VADs were associated with an HR of 1.91 (95% CI: 1.53 to 2.37; p < 0.0001) for mortality in the first 6 months and an HR of 2.93 (95% CI: 1.19 to 7.25; p = 0.02) beyond 5 years. The HRs were not significantly different from 1 between 6 months and 5 years, except for an HR of 0.23 (95% CI: 0.06 to 0.91; p = 0.04) between 24 and 36 months.

Conclusions: Extracorporeal VADs are associated with higher mortality within 6 months and again beyond 5 years after transplantation. Intracorporeal VADs are associated with a small increase in mortality in the first 6 months and a clinically significant increase in mortality beyond 5 years. These data do not provide evidence supporting VAD implantation in stable United Network for Organ Sharing status I patients awaiting heart transplantation.

Key Words: heart-assist devices • ventricular assist device • mortality • outcome • heart transplantation

Abbreviations and Acronyms   HR = hazard ratio   IABP = intra-aortic balloon pump   PRA = panel reactive antibodies   UNOS = United Network for Organ Sharing   VAD = ventricular assist device

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