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As a bridge to transplant strategy, children transitioned from extracorporeal membrane oxygenation (ECMO) to ventricular assist device (VAD) have higher waitlist mortality compared with those who receive de novo VAD. However, the contribution of the immediate perioperative period and differences in the two groups are not well studied. We performed a nested case-control study between children receiving de novo VAD (group 1) and those transitioned from ECMO to VAD (group 2) between 2014 and 2019 using The Society of Thoracic Surgeons (STS) database. A total of 735 children underwent VAD placement with 498 in group 1 and 237 in group 2. Patients in group 2 were significantly younger, smaller, and significantly sicker, were twice as likely to transition to biventricular VAD and need unplanned reoperations. Overall mortality was 16% for group 1 and 34% for group 2 ( p < 0.01). Regression analysis showed that ECMO use (odds ratio [OR], 2.17 [1.3-3.4]), ventilator need (OR, 2.2 [1.3-3.9]), and cardiogenic shock (OR, 1.8 [1.2-2.8]) were all independent preoperative predictors of VAD mortality while dialysis need (OR, 25.5 [8.6-75.3]), stroke (OR, 6.2 [3.1-12.6]), and bleeding (OR, 1.9 [1.1-3.4]) were independent postoperative predictors of VAD mortality within 30 days (all p < 0.05). The study demonstrated significant baseline differences between the two cohorts, warranting avoidance of comparison. Early elective VAD placement in this cohort of patients should be sought to avoid interim ECMO and high post-VAD mortality., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the ASAIO.)

The new United Network for Organ Sharing (UNOS) policy has resulted in a significantly higher number of temporary mechanical circulatory support device usage such as extracorporeal membrane oxygenation, Impella, and intra-aortic balloon pump due to provision of higher priority with their use while on the waiting list. We aimed to identify Impella use in patients awaiting heart transplantation and temporal changes in its usage. The UNOS database was queried between years 2015 and 2019 for patients aged greater than or equal to 18 years, listed to undergo heart transplantation. A total of 378 patients had Impella support while listed for heart transplantation. Impella use skyrocketed from 2015 (1%) to 2019 (4%, p < 0.01). The most substantial increase in Impella use occurred after the UNOS policy change. The patients listed on Impella support after the policy change had significantly lower waiting time (median 12 days vs. 45 days, p < 0.01). More patients with Impella were directly transplanted (80% vs. 56%, p < 0.01) after the policy change, had significantly lower waitlist mortality (25% vs. 13%, p < 0.01) and fewer converted to a durable support (13% vs. 3%). The translatability (likelihood for receiving organs faster) was significantly improved after the policy change. A multivariable Cox regression model showed that post-transplant survival of Impella patients was not adversely affected after the policy change (hazard ratio = 0.9; p = 0.8). This increase in Impella use represents a substantial change in practice patterns of listing and managing patients on the heart transplant waiting list., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2021.)

Objectives: This study aimed to compare the clinical characteristics, risk factors, and overall survival outcomes in adults with congenital heart disease (ACHD) bridged to transplantation with a ventricular assist device (VAD) versus no-VAD., Methods: The study included 894 ACHD patients aged ≥18 years listed for primary heart transplantation between 2010 and 2019 from the United Network for Organ Sharing database. Primary outcomes were waitlist and 1-year post-transplant mortality between VAD and no-VAD ACHD patients., Results: Of 894 ACHD patients included in the study, 91(10.1%) had VAD support at the time of listing. Patients who needed VAD support were mostly males, heavier, and had higher pulmonary artery pressure than the no-VAD group at the listing. The overall waitlist mortality was 38% in the VAD group than 17% in the no-VAD group (p < 0.01). ECMO use was associated with significantly higher mortality than either group. There was no significant difference in 1-year post-transplant mortality between VAD versus no-VAD at the time of transplant (15% vs. 17%; p = 0.66). Multivariate regression analysis found that BMI <20 kg/m 2 (hazard ratio (HR) 1.1; p = 0.01), bilirubin >2 mg/dl (HR 1.1; p = 0.03), creatinine >2 mg/dl (HR 1.3; p = 0.04) and ECMO at transplant (HR 1.4; p = 0.03) increased early post-transplant mortality., Conclusions: The one-year post-transplant mortality rate was no different for ACHD patients that received VAD versus no-VAD. These findings suggest that a VAD should be considered an option to support ACHD patients as a bridge to heart transplantation., (© 2021 International Center for Artificial Organs and Transplantation and Wiley Periodicals LLC.)

Background: Use of continuous-flow left ventricular assist devices (LVAD) has increased over the years as a bridge to transplant. The HeartWare HVAD (Medtronic, Minneapolis, MN) and HeartMate III (HM3, Abbott, Abbott Park, IL) are currently approved centrifugal-flow devices used for bridge to transplant. We sought to evaluate outcomes of the patients listed and who received a transplant after receiving these 2 devices., Methods: The United Network of Organ Sharing thoracic transplant database was queried after August 23, 2017, until December 2018 to identify patients aged older than 18 years listed for heart transplant and supported by the HVAD or HM3. Patient characteristics were evaluated at the time of listing and transplant. The primary study end point was 1-year mortality after LVAD implantation. Nonparametric tests were used to evaluate the device groups., Results: Of 569 patients listed for heart transplant during the study period, 226 had HM3 and 343 had HVAD. The HM3 group had more men (82% vs 74%, P = .02), patients with diabetes (38% vs 29%, P = .02), and the body mass index was higher (28 vs 27 kg/m 2 , P = .04) at listing. Between the HM3 and HVAD groups, the 1-year mortality was 20% vs 17%, respectively (log-rank P = .28; Figure 1), and the posttransplant survival at 1 year was 97% and 94%, respectively (P = .1)., Conclusions: In a relatively well-matched group of patients listed for heart transplant with a centrifugal-flow LVAD, the 6-month and 1-year mortality on the waiting list as well as after transplant were not statistically different. Additional real-world experience or a randomized trial would be needed to determine whether one LVAD is superior., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The objective of this study was to evaluate annual heart transplant volumes and 3-year post-transplant outcomes since establishment of United Network for Organ Sharing (UNOS) database stratified by race., Methods: The UNOS thoracic transplant database was evaluated for adult patients since 1987. The available database was then stratified by Race: Black, White and Other and era of transplant: group 1(1987-1991), group 2(1992-1996), group 3(1997-2001), group 4(2002-2006), group 5(2007-2011), group 6(2012-2016) and group 7(2017 and later). Demographic and clinical factors were evaluated., Results: A total of 105,266 adults have been listed since 1987 and 67,824 have been transplanted. Of the transplanted patients 11,235 were Black, 48,786 White and 6803 were of Other race. The proportion of Black patients listed increased from 7% in 1987 to 13.4% in 1999 and 25% in 2019 and those transplanted increased from 5% in 1987 to 13.4% in 2001 and 26% in 2019. The survival of Black patients gradually improved., Conclusion: Historically, fewer Black patients received cardiac transplantation however, their access gradually improved over the years and account for over 25% of cardiac transplantations performed in recent years. The historically poor survival of Black patients has recently improved and became comparable to the rest., Competing Interests: The authors have declared that no competing interests exist.

Background: Donor utilization rates continue to be low for pHT, however, efforts to expand the donor acceptance criteria have shown mixed results in single-institution studies in pediatric and adult transplantation. Purpose of this study is to assess impact of individual and cumulative donor risk factors on transplant outcomes as well as the interplay between donor and recipient risk factors as it relates to transplant outcomes., Method: We analyzed pHT UNOS data (2008-2018) to compare the recipient characteristics, donor characteristics, and outcomes based on donor ejection fraction of less than 50% (low EF) and or ischemic time of greater than 4 hours (prolonged IT)., Results: A total of 4345 pHT were performed of which 1309 (30.1%) were with prolonged IT and 122 (2.8%) in low EF. Additionally, 58 (1.3%) were performed with both low EF and prolonged IT (combined risk). Rest (2856 patients, 65.7%) was considered low risk. Recipients of combined risk were more likely to be younger, have post-surgical congenital heart disease, be on ECMO or ventilator but less likely on VAD (all P < .01) compared with any other group. Waitlist time was significantly lower for low EF (mean 39 days, 15-109) or combined risk group (36 days, range 15-80) compared with other groups (60 days, range 23-125) (P = .01). 1-year mortality was 8% in low-risk group, 12% in prolonged IT, 14% in reduced EF, and 28% in combined risk patients (P < .01). Number of treated rejections in one year were significantly higher in prolonged IT and combined risk group compared to other groups (P < .01). When stratified by recipient risk, there was no difference in outcomes for low risk, prolonged IT, or low EF groups; however, there were significant survival differences for high-risk recipient versus low-risk recipient in each donor group., Conclusion: Lower EF donors performed similar to prolonged IT donor, but were uncommonly used. Acceptance of risk was common in recipients deemed higher risk for waitlist mortality and led to shorter wait times. Caution should be used in accepting combined risk transplants. The recipient risk factors have significant impact on outcomes across all donor risk groups and further analysis will help balance the waitlist mortality with post-transplant outcomes., (© 2020 Wiley Periodicals LLC.)

Competing Interests: Disclosure: The authors have no conflicts of interest to report.

Objectives: In patients with reduced kidney function there are no established guidelines to suggest combined heart-kidney transplant (HKTx) versus sequential kidney transplant (SKTx) using preoperative value of estimated glomerular filtration (eGFR)., Methods: The United Network for Organ Sharing database was queried from 2000 to 2015 to evaluate survival of HKTx and SKTx population stratified by preoperative eGFR rate <45 mL/min. Aim of the study was to assess the eGFR rate that is most beneficial to perform a concomitant or a SKTx at time of transplant evaluation., Results: In our analysis, patients who required SKTx are recipients that, after heart transplantation, developed or worsened kidney insufficiency due to calcineurin inhibitor nephrotoxicity. In recipients with eGFR <30 or dialysis, a total of 545 received HKTx and 80 received SKTx. The median waiting time between heart and kidney transplant in SKTx group was 6 years. The overall post-transplant survival was 81% and 80% and 75% and 59% at 5 and 1 years for the HKTx and SKTx groups, respectively (P = .04). In recipients with eGFR from 30 to 44, a total of 107 received HKTx and 112 received SKTx. The median waiting time between heart and kidney transplant in SKTx group was 4 years. Overall post-transplant survival showed no statistically significant differences in HKTx group (n=107) compared with SKTx group (n=112) and was 90% and 95% at 1 year and 74% and 52% at 5 years, respectively (P = .4) ., Conclusions: To optimize organ and patient survival, eGFR value can be utilized to discern between HKTx versus SKTx in patients with decreased renal function at the time of heart transplantation. Patients with eGFR<30 or in dialysis presented better survival with HKTx, while both SKTx and HKTx are suitable for patients with eGFR between 30 and 45., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Recent reports have shown an increase in the number of organ donors from drug intoxication. The impact of donor drug use on survival after cardiac transplant remains unclear. The aim of our study was to illustrate changes in donor death mechanisms and assess the impact on posttransplant survival. We queried United Network of Organ Sharing thoracic transplant and deceased donor databases to identify patients undergoing heart transplantation between 2005 and 2015. We evaluated annual trends in donor death mechanisms. Recipients were propensity matched (drug-intoxicated-non-drug-intoxicated = 1:2) and posttransplant survival was compared using Kaplan-Meier curves. In total, 19 384 donor hearts were used for transplant during the period (donor age 31.6 ± 11.8 years, 72% male). Use of drug-intoxicated donors increased from 2% (2005) to 13% (2015) and decreased from blunt injury (40%-30%) and intracranial hemorrhage (29%-25%). After propensity matching, posttransplant survival of drug-intoxicated donor hearts was 90%, 82%, and 76% at 1, 3, and 5 years, which was similar to non-drug-intoxicated. Heart transplants using drug-intoxicated donors have significantly increased; however, they have not adversely affected posttransplant survival. Hearts from drug-intoxicated donors should be carefully evaluated and considered for transplant., (© 2018 The American Society of Transplantation and the American Society of Transplant Surgeons.)

The effects of pulmonary hypertension (PAH) on survival after heart transplantation are debated, especially for patients with left ventricular assist devices (LVAD). The United Network of Organ Sharing database was retrospectively queried from January 2005 to June 2015 to identify adult patients who underwent heart transplantation. Four groups were defined: patients without PAH, persistent PAH, resolved PAH, and developed PAH between listing and transplant. A total of 15,914 patients underwent heart transplant of which 4,662 (29%) were implanted with an LVAD. Of the total population, 10,872 (68%) had PAH at time of listing and 9,661 (61%) had PAH at time of transplant. Long-term survival was significantly worse for patients with an LVAD than for those without who had PAH at time of transplant (p = 0.010). Kaplan-Meier analysis showed a trend of worse long-term survival for patients with an LVAD who developed PAH by the time of transplant but improved survival for patients with resolved PAH while on LVAD therapy (p = 0.052). PAH at time of transplant results in worse long-term survival for patients with an LVAD. Furthermore, the development of PAH while on LVAD therapy may negatively impact long-term post-transplant survival, while resolution of PAH improves long-term survival.

Background: Optimum use of donor organs can increase the reach of the transplantation therapy to more patients on waiting list. The heart transplantation (HTx) has remained stagnant in United States over the past decade at approximately 2,500 HTx annually. With the use of the United Network of Organ Sharing (UNOS) deceased donor database (DCD) we aimed to evaluate donor factors predicting donor heart utilization., Methods: UNOS DCD was queried from 2005 to 2014 to identify total number of donors who had at least one of their organs donated. We then generated a multivariate logistic regression model using various demographic and clinical donor factors to predict donor heart use for HTx. Donor hearts not recovered due to consent or family issues or recovered for nontransplantation reasons were excluded from the analysis., Results: During the study period there were 80,782 donors of which 23,606 (29%) were used for HTx, and 38,877 transplants (48%) were not used after obtaining consent because of poor organ function (37%), donor medical history (13%), and organ refused by all programs (5%). Of all, 22,791 donors with complete data were used for logistic regression (13,389 HTx, 9,402 no-HTx) which showed significant predictors of donor heart use for HTx. From this model we assigned probability of donor heart use and identified 3,070 donors with HTx-eligible unused hearts for reasons of poor organ function (28%), organ refused by all programs (15%), and recipient not located (9%)., Conclusions: An objective system based on donor factors can predict donor heart use for HTx and may help increase availability of hearts for transplantation from existing donor pool., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Heart transplantation remains the gold standard therapy for end-stage heart failure patients; however, volumes are limited because of donor organ shortage. With the increasing availability of more durable continuous flow left ventricular assist devices (CFLVADs), the matrix of the heart transplantation waiting list and that of donor allocation have seen substantial changes. We aimed to evaluate the impact of the stated reasons for status 1A at time of transplantation on post-transplantation survival in CFVAD patients., Methods: The United Network of Organ Sharing (UNOS) thoracic organ transplantation database was queried between 2006 and 2013 to identify patients aged 18 years or older who underwent heart transplantation as UNOS status 1A. We further assessed the data to identify reasons for status 1A at time of transplantation in CFVAD patients. We also computed post-transplantation survival of patients supported with CFLVAD who were status 1A at the time of transplantation., Results: A total of 15,779 patients underwent heart transplantation during the study time period, of whom 8,429 were Status 1A, and 3,913 had CFLVAD at time of transplantation. Of all status 1A patients, 2,737 had CFLVAD at time of transplantation, of which 52% (1,413) had device complications (thrombosis, infection, malfunction, and other) and 48% (1,314) were on 30-day grace status 1A. Post-transplantation survival (at 3 years) of CFLVAD patients who received a transplant on 30-day grace status 1A was similar to patients who underwent transplantation on status 1B (84% versus 85%, p = 0.5), both of which were significantly better than status 1A patients because of device complications (84% and 85% versus 78%, p = 0.01) (Fig 1)., Conclusions: CFLVAD patients who underwent transplantation as Status 1B or on the 30-day grace Status 1A have similar post-transplantation survival. These data suggest that there needs to be an objective organ allocation system for recipients of heart transplant that prioritize patients with CFVAD complications and patients not eligible for CFVAD for transplantation over 30-day grace period patients., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The use of left ventricular assist devices (LVAD) has increased significantly in the last decade. However, right heart dysfunction remains a problem despite the improved outcomes with continuous-flow LVADs. Surgical options for bridge to transplantation (BTT) in patients with biventricular failure are total artificial heart (TAH) or biventricular support (BiVAD). This study examines the differences in pre- and post-transplantation outcomes and survival in patients with TAH or BiVAD support as BTT., Methods: The United Network of Organ Sharing database was retrospectively queried from January 2005 to December 2014 to identify adult patients undergoing heart transplantation (n = 17,022). Patients supported with either TAH (n = 212) or BiVAD (n = 366) at the time of transplantation were evaluated. Pre- and post-transplantation Kaplan-Meier survival curves were examined. Cox regression model was used to study the hazard ratios of the association between TAH versus BiVAD support and post-transplant survival., Results: The median age of the study groups was 49.8 ± 12.9 (TAH) and 47.2 ± 13.9 (BiVAD) years (range 18-74 years). There were more men, 87% versus 74%, in the TAH group (p < 0.0001) with greater body mass index, 27.3 ± 5.2 versus 25.6 ± 4.7 (p < 0.0001), compared to those with BiVADs. Creatinine was higher, 1.7 + 1.2 versus 1.3 + 0.8 mg/dL (p < 0.0001), in the TAH group before transplant. The 30-day, one-, and three-year post-transplantation survival was 88%, 78%, and 67%, respectively, for patients with TAH support versus 93%, 83%, and 73% (p = 0.06) for patients with BiVAD support. Cox regression model shows pre-transplant creatinine (HR = 1.21, p = 0.008) is associated with a lower post-transplant survival. TAH is not associated with a worse post-transplant survival (p = 0.1). There was no difference in wait-list survival in patients supported with TAH or BiVAD (p = 0.8)., Conclusion: Although there has been a recent increase in the use of the TAH as BTT, BiVAD support remains a viable option with similar post-transplant survival., (© 2016 Wiley Periodicals, Inc.)

Background: Donor heart availability has limited the number of heart transplants performed in the United States, while the number of patients waiting for a transplant continues to increase. Optimizing the use of all available donor hearts is important to reduce waiting list deaths and to increase the number of patients who can ultimately undergo a successful heart transplant. Donor cardiopulmonary resuscitation (CPR) time has been proposed to be a selection criterion to consider in donor selection. This study examined whether the duration of donor CPR time affects recipient posttransplantation outcomes and survival., Methods: The United Network of Organ Sharing database was retrospectively queried from January 2005 to December 2013 to identify adult patients who underwent heart transplantation. This population was divided into four groups: donors with no CPR, CPR of less than 20 minutes, CPR of 20 to 30 minutes, and CPR exceeding 30 minutes. Kaplan-Meier analysis was used to compare the recipient posttransplant survival between groups, and posttransplant outcomes were examined. Propensity matching was performed for comparison of posttransplant survival of recipients of donors who did and did not undergo CPR. Multivariable logistic regression analysis was performed to examine individual independent variables for death after transplant., Results: During this period, 17,022 patients underwent heart transplantation. Of those, 16,042 patients received hearts from a donor with no CPR, 639 patients with donor CPR of less than 20 minutes, 154 patients with donor CPR 20 to 30 minutes, and 187 patients with donor CPR exceeding 30 minutes. The posttransplant survival at 1 year for each group was 89% vs 90% vs 88% vs 89% and at 5 years was 75% vs 74% vs 74% vs 72%, respectively, which was not significantly different among the groups. Recipient primary graft failure and rejection rates were similar among the groups. The multivariable regression model showed CPR duration was not an independent risk factor for posttransplant death., Conclusions: Donor CPR does not significantly affect outcomes and survival after transplant. In an effort to optimize donor heart use, donor CPR time alone should not be used to rule out the acceptance of a potential donor heart., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Donor to recipient undersizing can result in diminished graft survival. The United Network for Organ Sharing database was retrospectively queried from January 2008 to December 2013 to identify adult patients who underwent heart transplantation. This population was divided into those without and with a left ventricular assist device (LVAD) at the time of transplant. Both groups were further subdivided into three groups: donor:recipient body mass index (BMI) ratio <0.8 (undersized), ≥0.8 and ≤1.2 (matched), and >1.2 (oversized). Kaplan-Meier analysis was used to compare graft survival. Cox regression analysis was used to identify factors affecting graft survival time. There was no difference in mean graft survival between undersized, matched, and oversized groups in patients without an LVAD (p = 0.634). Mean graft survival was significantly worse for undersized patients with an LVAD when compared with matched and oversized patients (p = 0.032). Cox regression revealed age, creatinine, waitlist time, United Network for Organ Sharing status, BMI ratio, and total bilirubin as significant factors affecting graft survival time. A donor to recipient BMI ratio of ≥1.2 results in significantly improved long-term graft survival for patients with an LVAD at the time of heart transplantation compared with patients with a BMI ratio of <1.2. An oversized organ should be considered for patients supported with an LVAD.

Unlike the lung allocation score, currently, there is no quantitative scoring system available for patients on heart transplant waiting list. By using United Network for Organ Sharing (UNOS) data, we aim to generate a scoring system based on the recipient and donor risk factors to predict posttransplant survival. Available UNOS data were queried between 2005 and 2013 for heart transplant recipients aged ≥18 years to create separate cox-proportional hazard models for recipient and donor risk scoring. On the basis of risk scores, recipients were divided into five groups and donors into three groups. Kaplan-Meier curves were used for survival. Total 17,131 patients had heart transplant within specified time period. Major factors within high-risk groups were body mass index > 30 kg/m (46%), mean pulmonary artery pressure >30 mmHg (65%), creatinine > 1.5 mg% (63%), bilirubin > 1.5 mg% (54%), noncontinuous-flow left ventricular assist devices (45%) for recipients and gender mismatch (81%) and ischemia time >4 hours (88%) for donors. Survival in recipient groups 1, 2, 3, 4, and 5 at 5 years was 81, 80, 77, 74, and 62%, respectively, and in donor groups 1, 2, and 3 at 5 years was 79, 77, and 70%, respectively (p < 0.001). Combining donor and recipient groups based on scoring showed acceptable survival in low-risk recipients with high-risk donor (75% at 5 years). A higher recipient and donor risk score are associated with worse long-term survival. A low-risk recipient transplanted with high-risk donor has acceptable survival at 5 years, but high-risk recipient combined with a high-risk donor has marginal results. Using an objective scoring system could help get the best results when utilizing high-risk donors.

Background: The shortage of donor hearts has limited cardiac transplantation for end-stage heart failure, leading to the increased use of left ventricular assist devices (LVADs) as bridge-to-transplant (BTT) and marginal donor hearts; however, outcomes have been mixed. This study examines differences in wait list survival of patients with continuous flow LVADs and post-transplantation survival of patients receiving a marginal donor heart., Methods: The United Network of Organ Sharing database was retrospectively queried from January 2005 to June 2013 to identify adult patients listed for heart transplant. Marginal donor criteria included age greater than 55 years, hepatitis C positive, cocaine use, ejection fraction less than 0.45, or donor to recipient body mass index mismatch of greater than 20%. The primary endpoint was wait list survival of patients with LVADs compared with post-transplant survival of marginal donor heart recipients using Kaplan-Meier analysis., Results: A total of 2,561 and 4,737 patients received LVAD support or a marginal donor heart, respectively. The 30-day, 1-year, and 2-year survival was 96%, 89%, and 85%, for patients with LVAD support on the waiting list and 97%, 89%, and 85%, respectively, for recipients of marginal donor hearts (p = 0.213). Recipients of marginal hearts had worse survival than non-marginal heart recipients at 3 years (p = 0.011)., Conclusions: There was no significant difference between waiting list survival of patients with LVAD support as BTT and post-transplant survival of recipients with marginal donor hearts. There could be clinical benefits for using LVAD support as BTT to allow time for better allocation of optimal donor hearts as opposed to transplantation with a marginal donor heart., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Continued donor organ shortage and improved outcomes with current left ventricular assist device (LVAD) technology have increased the number of patients supported with bridge-to-transplantation (BTT) therapy. Using the United Network of Organ Sharing (UNOS) database, we assessed the impact on survival in patients supported with BTT while on the heart transplant waiting list., Methods: The UNOS database was queried from January 2005 to June 2012 to identify patients listed for heart transplantation as UNOS status 1A or 1B. Patients implanted with a pulsatile-flow device or an LVAD other than the HeartMate II (HM II; Thoratec Inc, Pleasanton, CA) were excluded. Patients were divided into LVAD and non-LVAD groups based on status at the time of listing. Patients were propensity matched (LVAD -non-LVAD = 1:2) for age, sex, weight, presence of diabetes, creatinine levels, mean pulmonary artery pressure, and UNOS status. Kaplan-Meier curves were analyzed for survival., Results: A total of 8,688 patients were analyzed, with 1,504 (17%) in the LVAD group. Average age (52.6 ± 11.8 versus 51.3 ± 12.9 years; p = 0.0002) and weight (86.6 ± 18.6 versus 80.8 ± 18.2 kg; p < 0.0001) at time of listing were higher in the LVAD group. There were more men (79% versus 74%; p < 0.0001) and more patients with diabetes (30% versus 27%; p = 0.03) in the LVAD group. Of all patients, 6,943 patients (80%) underwent transplantation, 862 (10%) died, and 883 (10%) remained on the waiting list. After propensity matching, survival to transplantation was significantly better in the LVAD group than in the non-LVAD group at both 1 year (91% versus 77%) and 2 years (85% versus 68%)., Conclusions: Patients supported with an HM II LVAD as BTT therapy were older with increased comorbidities; they demonstrated an improved survival while listed for heart transplantation. The use of LVADs as a BTT strategy can potentially improve patient survival while waiting for transplantation and allow better allocation of donor hearts., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Previous United Network for Organ Sharing (UNOS) analysis has shown an increase in posttransplant mortality with pretransplant pulsatile-flow left ventricular assist device (LVAD). Recent studies evaluating continuous-flow LVAD demonstrated improved durability, excellent survival, and improved quality of life. This study investigates the association of preheart transplant continuous-flow LVAD placement and posttransplant mortality using the UNOS database. Heart transplant patients listed after April 2004 (N = 48,090) during the era of HeartMate (HM) II LVAD usage were investigated. Patients with UNOS 1A and 1B status with (n = 1,435) and without HMII (n = 16,379) placement before the heart transplantation were evaluated. Preliminary descriptive statistics suggested an extensive heterogeneity in patient characteristics between HMII LVAD recipients and nonrecipients. Propensity scores (1:2) were used to match HMII LVAD recipients and nonrecipients characteristics and donor characteristics. This resulted in a final sample of 2,265 patients (758 with HMII pretransplant placement and 1,507 without HMII pretransplant placement). The Kaplan-Meier curves were evaluated for the differences in postheart transplant mortality in patients with and without HMII pretransplant placement. A time-dependent Cox regression model was used to study the hazard ratios (HRs) for the association between HMII pretransplant placement and posttransplant survival. The mean age of the study group was 51.9 years old (standard deviation: 12.3). HeartMate II pretransplant placement was associated with no statistically significant difference in the risk of 30 days (HR = 1.23, 95% confidence interval [CI]: 0.79-1.95, p = 0.36) and 1 year posttransplant mortality (HR = 1.31, 95% CI: 0.85-2.01, p = 0.22) compared with non-HMII recipients. The use of HMII LVAD before heart transplantation, however, was associated with a statistically significant 64% lower risk (HR = 0.36, 95% CI: 0.16-0.77, p = 0.01) of mortality among heart transplant patients who survived beyond the first year of transplantation. Continuous-flow LVAD pretransplant placement is associated with improved long-term (>1 year) survival after heart transplantation.

Background: Patients listed for heart transplant have a prolonged wait time, with continued deterioration, poor quality of life, and 10% mortality. Although recent bridge to transplant (BTT) studies demonstrated 1-year survival similar to heart transplantation, doubt remains about overall effectiveness as a treatment strategy compared with waiting and implanting a left ventricular device (LVAD) only as a last resort. We evaluated 1-year outcome and effectiveness of LVAD vs heart transplantation., Methods: Patients on the heart transplantation list, either receiving an allograft or LVAD for BTT from January 2009 to December 2009 were evaluated. Of 43 patients treated, 1 received both LVAD and an allograft during same admission was removed from the analysis. All patients but one who received an allograft had prior LVAD. Descriptive and univariate (t test) statistics and Kaplan-Meier survival curve were used for analyses., Results: LVAD for BTT was used in 29 patients (51.4±12.8 years, 6.9% women), and 13 (51.1±11.6 years, 15.38% women) underwent heart transplantation. Initial hospital length of stay was 17.5±14.4 days in BTT group and 14.3±4.6 days in heart transplant group (p=0.44) At 1 year, the total number of days spent in the hospital (operation and related complications), including index hospitalization was 11.6±14.3 days/100 days in BTT and 7.9±9.0 days/100 days in heart transplantation (p=0.38). A total of 41% BTT and 46% heart transplant patients had one readmission within 3 months of the index hospitalization. Infection was the most common cause of readmission in both groups. The 1-year survival was similar for both groups (no hospital death in either group; 3 late deaths in the BTT group)., Conclusions: One-year outcomes for patients eligible for heart transplantation were similar whether they received an allograft or LVAD for BTT. Heart transplant outcome for patients with LVAD were not adversely affected. Improving outcomes for patients treated with LVAD suggest that current decision models for patients eligible for heart transplantation may need to be reevaluated., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Implantable cardioverter‐defibrillators (ICDs) have been shown to have survival advantage in advanced heart failure patients. Few studies have evaluated the role of ICDs in patients supported with continuous‐flow left ventricular assist devices (CFVADs). We aimed to evaluate the impact of ICD and CFVAD on heart transplant (HTx) waiting list survival. We queried the United Network for Organ Sharing (UNOS) thoracic transplant database between years 2007 and 2016 for patients aged ≥ 18 years listed for HTx. Patients receiving devices other than CFVAD were excluded. Patients were divided into groups—with and without CFVAD and further subdivided into groups—with and without ICD use. Kaplan‐Meier curves were used to evaluate the survival outcomes. There were 34 860 patients listed for HTx during study period of which 11 481 (32%) had a CFVAD and 26 139 (75%) had an ICD. Within CFVAD group, patients with ICD were older, more likely male, with higher creatinine and listed as UNOS status 1A. In the No‐CFVAD group, 1‐year waitlist survival was significantly better with ICD use (81% vs. 73%, P <.0001); however, in CFVAD patients, 1‐year survival with ICD use was comparable to No‐ICD use (95% vs. 94%, P =.1). Use of ICD is associated with significantly better heart transplant waitlist survival in patients not supported by CFVAD. In patients supported with CFVAD, the ICD does not offer additional survival benefit. [ABSTRACT FROM AUTHOR]

Cardiac resynchronization therapy (CRT) improves outcomes in heart failure patients with wide QRS complex. However, CRT management following continuous flow Left Ventricular Assist Device (LVAD) implant vary: some centers continue CRT while others turn off the left ventricular (LV) lead at LVAD implant. We sought to study the effect of continued CRT versus turning off CRT pacing following continuous flow LVAD implantation. A comprehensive retrospective multicenter cohort of 295 patients with LVAD and pre-existing CRT was studied. CRT was programmed off after LVAD implant in 44 patients. We compared their outcomes to the rest of the cohort using univariate and multivariate models. Mean age was 60 ± 12 years, 83% were males, 52% had ischemic cardiomyopathy and 54% were destination therapy. Mean follow-up was 2.4 ± 2.0 years, and mean LVAD support time was 1.7 ± 1.4 years. Patients with CRT OFF had a higher Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) mean profile (3.9 vs 3.3, p = 0.01), more secondary prevention indication for a defibrillator (64.9% vs 44.5%, p = 0.023), and more pre-LVAD ventricular arrhythmias (VA) (77% vs 60%, p = 0.048). There were no differences between the CRT OFF and CRT ON groups in overall mortality (Log rank p = 0.32, adjusted HR = 1.14 [0.54–2.22], p = 0.71), heart transplantation, cardiac and noncardiac mortality, all cause hospitalizations, hospitalizations for ICD shocks, and number and frequency of ICD shocks or anti-tachycardia pacing therapy. There were no differences in post LVAD atrial arrhythmias (AA) (Adjusted OR = 0.45 [0.18–1.06], p = 0.31) and ventricular arrhythmias (OR = 0.65 [0.41–1.78], p = 0.41). There was no difference in change in LVEF, LV end diastolic and end systolic diameters between the 2 groups. Our study suggests that turning off CRT pacing after LVAD implantation in patients with previous CRT pacing did not affect mortality, heart transplantation, device therapies or arrhythmia burden. A prospective study is needed to confirm these findings. [ABSTRACT FROM AUTHOR]