Division of Cardiovascular Diseases, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
J Card Fail. 2024 Apr;30(4):552-561. doi: 10.1016/j.cardfail.2023.09.011. Epub 2023 Oct 26.
Left ventricular assist devices (LVADs) have been implanted as bridge to transplantation (BTT), bridge to candidacy (BTC) or destination therapy (DT) on the basis of relative and absolute contraindications to transplantation. Multiple factors may lead to changes in the strategy of support after LVAD implantation.
Based on INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) 2012-2020 data, 11,262 patients survived to 3 months on continuous-flow LVADs with intent of BTT or DT. Preimplant characteristics and early events post-LVAD were analyzed in relation to changes in BTT or DT strategy during the next 12 months.
Among 3216 BTT patients at 3 months, later transplant delisting or death without transplant occurred in 536 (16.7%) and was more common with age, profiles 1-2, renal dysfunction, and independently for prior cardiac surgery (HR 1.25, 95% CI 1.04-1.51; P = 0.02). Post-LVAD events of infections, gastrointestinal bleeding, stroke, and right heart failure as defined by inotropic therapy, predicted delisting and death, as did in-hospital location at 3 months (HR 1.67, 95% CI 1.20-2.33; P = 0.0024). Of 8046 patients surviving to 3 months with the intent of destination therapy, 750 (9.3%) subsequently underwent listing or transplantation, often with initial histories of acute HF (HR 1.70, 95% CI 1.27-2.27; P = 0.0012) or malnutrition-cachexia (1.73, 95% CI 1.14-2.63; P = 0.0099). Multiple gastrointestinal bleeding events (≥ 4) with LVAD increased transition from BTT to DT (HR 4.22, 95% CI 1.46-12.275; P = 0.0078) but also from DT to BTT (HR 5.17, 95% CI 1.92-13.9; P = 0.0011).
Implant strategies change over time in relation to preimplant characteristics and adverse events post implant. Preimplant recognition of factors predicting later change in implant strategy will refine initial triage, whereas further reduction of post-LVAD complications will expand options, including eventual consideration of heart transplantation.
左心室辅助装置（LVAD）已被植入作为桥接移植（BTT）、桥接候选资格（BTC）或目的地治疗（DT），这是基于相对和绝对移植禁忌症。多种因素可能导致 LVAD 植入后支持策略发生变化。
基于 INTERMACS（机械循环支持机构间注册）2012-2020 年的数据，11262 名连续流动 LVAD 患者存活至 3 个月，其意图为 BTT 或 DT。分析植入前特征和 LVAD 植入后早期事件与接下来 12 个月内 BTT 或 DT 策略的变化之间的关系。
在 3 个月时的 3216 名 BTT 患者中，536 名（16.7%）随后出现移植失访或死亡，而年龄较大、1-2 型、肾功能障碍以及先前心脏手术更为常见（HR 1.25，95%CI 1.04-1.51；P=0.02）。LVAD 后发生感染、胃肠道出血、中风和右心衰竭等事件，以及 3 个月时的住院地点（HR 1.67，95%CI 1.20-2.33；P=0.0024），也预示着失访和死亡。在存活至 3 个月且意图为 DT 的 8046 名患者中，750 名（9.3%）随后被列入名单或接受移植，其中许多人有急性 HF（HR 1.70，95%CI 1.27-2.27；P=0.0012）或营养不良-恶病质（1.73，95%CI 1.14-2.63；P=0.0099）的初始病史。LVAD 多次发生胃肠道出血事件（≥4 次）会增加从 BTT 向 DT 的转变（HR 4.22，95%CI 1.46-12.275；P=0.0078），但也会从 DT 向 BTT 转变（HR 5.17，95%CI 1.92-13.9；P=0.0011）。
随着时间的推移，植入策略会因植入前特征和植入后不良事件而发生变化。在植入前识别预测后期植入策略变化的因素将完善初始分诊，而进一步减少 LVAD 后并发症将扩大选择范围，包括最终考虑心脏移植。
