Thursday, January 15, 2009

Post heart transplant mortality seen higher with pretransplant ventricular assist device support

A bridge too far? Posttransplant mortality seen higher with pretransplant VAD support

By Steve Stiles theheart.org

Worcester and Boston, MA - Transplant-listed patients supported on a ventricular assist device (VAD) while awaiting a donor heart are more likely to die within the first six months after the surgery than transplanted patients who hadn't been bridged with a VAD, according to an analysis based on United Network for Organ Sharing (UNOS) data that date from several years to more than a decade ago [1]. The mortality increase in bridged patients dissipated after the six-month posttransplant period but appeared again five years later.

Given these findings, according to the authors, led by Dr Vishnu Patlolla (University of Massachusetts Medical School, Worcester), "we cannot recommend VAD implantation with a view to improving posttransplant survival for patients who are stable on intravenous inotropic therapy."

The group goes on to acknowledge that their data are based on early-generation pulsatile-pump VADs and can't be extrapolated to the newer continuous-flow models, "which are gaining popularity."

Their analysis appears in the January 20, 2008 issue of the Journal of the American College of Cardiology.

In an accompanying editorial [2], Dr Leslie Miller (Washington Hospital Center, Washington, DC) notes that the continuous-flow VADs "have been shown to have significantly better survival and quality of life and significantly lower adverse events than the previous generation of pulsatile devices."

Moreover, he writes, "the outcomes with medical therapy of status-1 patients with and without VAD support have improved over the past five years, and a more recent examination of the data would be helpful in determining whether the observations made are accurate in the current era."

Another expert in this patient population, Dr Randall C Starling (Cleveland Clinic, OH), said to heartwire that the report from Patlolla et al "is thought-provoking and hypothesis-generating," but he doesn't believe it will change practice at his institution. "I think it's going to raise questions, but it's not going to answer questions."

In the analysis of adults undergoing first-time, single-organ heart transplantation in the US from 1995 to 2004, 1433 patients were bridged with intracorporeal VADs (including devices from Thoratec Corp and WorldHeart) and 448 were bridged with extracorporeal VADs (including devices from Thoratec and Abiomed). They were compared with 9455 transplant candidates classified as UNOS status 1 who were not bridged with a VAD. The median follow-up times were 36.5, 24.4, and 49 months, respectively.

For a table of hazard ratios and references to other studies that question the validity of these findings read the full article.

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