Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany.
Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany.
Eur J Cardiothorac Surg. 2024 Oct 1;66(4). doi: 10.1093/ejcts/ezae333.
Bridging from a temporary microaxial left ventricular assist device (tLVAD) to a durable left ventricular assist device (dLVAD) is playing an increasing role in the treatment of terminally ill patients with heart failure. Scant data exist about the best implant strategy. The goal of this study was to analyse differences in the dLVAD implant technique and effects on patient outcomes.
Data from 341 patients (19 European centres) who underwent a bridge-to-bridge implant from tLVAD to dLVAD between January 2017 and October 2022 were retrospectively analysed. The outcomes of the different implant techniques with the patient on cardiopulmonary bypass, extracorporeal life support or tLVAD were compared.
A durable LVAD implant was performed employing cardiopulmonary bypass in 70% of cases (n = 238, group 1), extracorporeal life support in 11% (n = 38, group 2) and tLVAD in 19% (n = 65, group 3). Baseline characteristics showed no significant differences in age (P = 0.140), body mass index (P = 0.388), creatinine level (P = 0.659), the Model for End-Stage Liver Disease (MELD) score (P = 0.190) and rate of dialysis (P = 0.110). Group 3 had significantly fewer patients with preoperatively invasive ventilation and cardiopulmonary resuscitation before the tLVAD was implanted (P = 0.009 and P < 0.001 respectively). Concomitant procedures were performed more often in groups 1 and 2 compared to group 3 (24%, 37% and 5%, respectively, P < 0.001). The 30-day mortality data showed significantly better survival after an inverse probability of treatment weighting in group 3, but the 1-year mortality showed no significant differences among the groups (P = 0.012 and 0.581, respectively). Postoperative complications like the rate of right ventricular assist device (RVAD) implants or re-thoracotomy due to bleeding, postoperative respiratory failure and renal replacement therapy showed no significant differences among the groups. Freedom from the first adverse event like stroke, driveline infection or pump thrombosis during follow-up was not significantly different among the groups. Postoperative blood transfusions within 24 h were significantly higher in groups 1 and 2 compared to surgery on tLVAD support (P < 0.001 and P = 0.003, respectively).
In our analysis, the transition from tLVAD to dLVAD without further circulatory support did not show a difference in postoperative long-term survival, but a better 30-day survival was reported. The implant using only tLVAD showed a reduction in postoperative transfusion rates, without increasing the risk of postoperative stroke or pump thrombosis. In this small cohort study, our data support the hypothesis that a dLVAD implant on a tLVAD is a safe and feasible technique in selected patients.
从临时微轴左心室辅助装置（tLVAD）过渡到耐用性左心室辅助装置（dLVAD）在治疗终末期心力衰竭患者中发挥着越来越重要的作用。关于最佳植入策略的数据很少。本研究的目的是分析不同的 dLVAD 植入技术和对患者结局的影响。
回顾性分析了 2017 年 1 月至 2022 年 10 月期间，341 名（来自 19 个欧洲中心）患者从 tLVAD 桥接到 dLVAD 的桥接植入数据。比较了在体外生命支持或 tLVAD 上进行有创性心肺复苏的不同植入技术的结果。
70%的患者（n=238，组 1）采用体外循环进行耐用性 LVAD 植入，11%（n=38，组 2）采用体外生命支持，19%（n=65，组 3）采用 tLVAD。基线特征显示年龄（P=0.140）、体重指数（P=0.388）、肌酐水平（P=0.659）、终末期肝病模型（MELD）评分（P=0.190）和透析率（P=0.110）无显著差异。与 tLVAD 植入前相比，组 3 术前接受侵入性通气和心肺复苏的患者明显较少（P=0.009 和 P<0.001）。与组 3 相比，组 1 和组 2 更常进行伴随手术（分别为 24%、37%和 5%，P<0.001）。30 天死亡率数据表明，在经过逆概率治疗加权后，组 3 的存活率明显提高，但 1 年死亡率在组间无显著差异（P=0.012 和 0.581）。术后并发症，如右心室辅助装置（RVAD）植入率或因出血、术后呼吸衰竭和肾脏替代治疗而再次开胸的发生率，在组间无显著差异。在随访期间，首次出现不良事件（如中风、导线感染或泵血栓形成）的无事件生存率在组间无显著差异。与 tLVAD 支持下的手术相比，术后 24 小时内的输血率在组 1 和组 2 中明显升高（P<0.001 和 P=0.003）。
在我们的分析中，从 tLVAD 过渡到无进一步循环支持的 dLVAD 并没有显示术后长期生存的差异，但报告了更好的 30 天生存率。仅使用 tLVAD 进行植入可降低术后输血率，而不会增加术后中风或泵血栓形成的风险。在这项小型队列研究中，我们的数据支持这样一种假设，即在选定的患者中，在 tLVAD 上植入 dLVAD 是一种安全可行的技术。
