Heart transplantation improves survival regardless of LVAD therapy
Patients who underwent heart transplant with or without bridge to transplant left ventricular assist device therapy had superior 5-year survival vs. those with LVAD destination therapy when matched on several clinical factors, a study found.
“Transplant remains the optimal therapy for mid- and long-term survival for patients with advanced heart failure,” Donna M. Mancini, MD, director of heart failure and transplantation for the Mount Sinai Health System, told Healio. “Whether newer LVADs associated with a reduced adverse effect profile will yield the same results needs to be investigated.”
Propensity-matched cohort analysis
In the study published in JAMA Cardiology, Anuradha Lala, MD, assistant professor of cardiology and of population health science and policy at Icahn School of Medicine at Mount Sinai, and colleagues analyzed data from 8,281 patients with end-stage HF from the United Network for Organ Sharing registry and the Interagency Registry for Mechanically Assisted Circulatory Support. Patients underwent therapy and heart transplant (n = 4,867; median age, 56 years; 75% men) or destination therapy alone (n = 3,414; median age, 64 years; 79% men).
Patients were propensity-score matched by sex, age, BMI, albumin level and serum creatinine level. This resulted in 3,411 patients who were wait-listed for heart transplant and either received bridge-to-transplant LVAD therapy (n = 1,607) or did not (n = 1,804).
The primary endpoint was 5-year survival.
In the propensity-score matched group, patients who received LVAD destination therapy were slightly older than those who were wait-listed for heart transplant (64 years vs. 60 years; P < .001). Sex did not significantly differ between these two groups (79.2% vs. 77.6%, respectively).
After matching and adjusting for clinical factors, patients who were wait-listed for heart transplant had better survival at 5 years compared with those who received LVAD destination therapy (RR = 0.42; 95% CI, 0.38-0.46). This increased survival was linked to heart transplant (adjusted RR for time-dependent transplant status = 0.27; 95% CI, 0.24-0.32).
“There have been significant advances in the development of left ventricular assist devices such that the short-term survival with these devices is now comparable to heart transplantation,” Mancini said in an interview. “As transplantation uses a scarce resource, it would be beneficial to identify patients who could have similar mid- or long-term outcomes with an LVAD as compared to transplant. We could then utilize organs for those patients who would benefit most from transplant.”
Preferable strategy
In a related editorial, Clyde W. Yancy, MD, MSc, vice dean of diversity and inclusion, Magerstadt Professor of Medicine, professor of medical social sciences and chief of the division of cardiology at Northwestern University Feinberg School of Medicine, associate director of Bluhm Cardiovascular Institute at Northwestern Memorial Hospital and deputy editor of JAMA Cardiology, and Gregg C. Fonarow, MD, director of the Ahmanson-UCLA Cardiomyopathy Center, co-director of the UCLA Preventive Cardiology Program, co-chief of the division of cardiology at UCLA and Eliot Corday Chair in Cardiovascular Medicine and Science, wrote: “An intentional strategy to offer heart transplant as definitive therapy for advanced heart failure appears preferable. Moreover, a well-developed evidence-based system of organ allocation that optimizes donor access is critical in the care of patients with advanced heart failure.”
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Donna M. Mancini, MD, can be reached at donna.mancini@mountsinai.org.
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