Temporary Mechanical Circulatory Support as a Bridge to Transplant: Can We Do Better?
Presented During:
Friday, September 20, 2024: 5:00PM - 6:30PM
Omni King Edward Hotel
Abstract No:
10152
Submission Type:
Abstract Submission
Authors:
Rithva Ramesh (1), Brandon Ferrell (2), Daniel Goldstein (2), Stephen Forest (2)
Institutions:
(1) Albert Einstein College of Medicine, Bronx, NY, (2) Montefiore Medical Center, Bronx, NY
Submitting Author:
Rithva Ramesh
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Albert Einstein College of Medicine
Albert Einstein College of Medicine
Co-Author(s):
Brandon Ferrell
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Montefiore Medical Center
Montefiore Medical Center
*Daniel Goldstein
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Montefiore Medical Center
Montefiore Medical Center
Stephen Forest
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Montefiore Medical Center
Montefiore Medical Center
Presenting Author:
Rithva Ramesh
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Albert Einstein College of Medicine
Albert Einstein College of Medicine
Abstract:
Objective:
Temporary circulatory support (TCS) devices are being used more frequently as bridge to heart transplant (BTT) following the 2018 UNOS allocation change. We aim to describe and compare the adverse event profile and outcomes associated with TCS as a BTT.
Methods:
A retrospective analysis of our institutional database was performed on all adult patients (≥18 years old) who were listed for cardiac transplantation from October 1st, 2018, until June 30th, 2024. Patients implanted with an intraaortic balloon pump (IABP) or a microaxial left ventricular assist device (mLVAD) capable of at least 5 liters of support were identified and included in our cohort. Demographics and preoperative characteristics were identified. Device related adverse events as reported in the medical record and defined by laboratory values were included. Patient outcomes were defined by transplantation, delisting, continued support, durable LVAD implantation, or death.
Results:
A total of 64 patients were included of which 49 (76.6%) received an IABP, 8 (12.5%) were implanted with a mLVAD, and 7 (10.9%) were implanted with both. Median age of the entire cohort was 57 years with 48 (75%) males. Nearly half of the patients had a prior history of arrhythmia (37, 58%), HTN (35, 55%), CKD (28, 44%), DM (29, 45%), and were former smokers (32, 50%). Cohorts for mLVAD and IABP were similar in comorbidities except for prior history of dialysis use (IABP 4, 8.2%; mLVAD 4, 50.0%; p < 0.01). The most common device related complication was hemolysis in 20 (31.3%) patients, more commonly in the mLVAD cohort (6, 75%) compared to the IABP group (8, 16.3%), p < 0.01. Bleeding (13, 20.3%) and infection (10, 15.6%) were less common with no significant difference between to the two groups. Stroke (2, 3%) and limb ischemia (1, 2%) were rare events overall. Twenty-seven patients (55.1%) in the IABP and one (12.5%) in the mLVAD cohort were free from complication, death, or emergent LVAD. Most patients were successfully bridged to transplant occurring in 57 (89%) patients, while 1 (2%) is currently waitlisted, and 6 (9%) were removed from the waitlist. Three patients expired while on device support and 4 required urgent implantation of a durable LVAD.
Conclusion:
TCS is a successful strategy to bridge patients to cardiac transplantation, but the burden of device related complications in this setting has not been well described. Our data demonstrates a significant risk of hemolysis, bleeding, and infection when using TCS as a bridge to transplant. While an overwhelming majority of patients are successfully transplanted, there are many that are either delisted or expire while on support, and even fewer who can be salvaged with a durable, implantable device. Consideration for organ allocation distribution to include temporary device adverse events in patients without a durable option as salvage therapy may be prudent to minimize waitlist death and removal.
Temporary circulatory support (TCS) devices are being used more frequently as bridge to heart transplant (BTT) following the 2018 UNOS allocation change. We aim to describe and compare the adverse event profile and outcomes associated with TCS as a BTT.
Methods:
A retrospective analysis of our institutional database was performed on all adult patients (≥18 years old) who were listed for cardiac transplantation from October 1st, 2018, until June 30th, 2024. Patients implanted with an intraaortic balloon pump (IABP) or a microaxial left ventricular assist device (mLVAD) capable of at least 5 liters of support were identified and included in our cohort. Demographics and preoperative characteristics were identified. Device related adverse events as reported in the medical record and defined by laboratory values were included. Patient outcomes were defined by transplantation, delisting, continued support, durable LVAD implantation, or death.
Results:
A total of 64 patients were included of which 49 (76.6%) received an IABP, 8 (12.5%) were implanted with a mLVAD, and 7 (10.9%) were implanted with both. Median age of the entire cohort was 57 years with 48 (75%) males. Nearly half of the patients had a prior history of arrhythmia (37, 58%), HTN (35, 55%), CKD (28, 44%), DM (29, 45%), and were former smokers (32, 50%). Cohorts for mLVAD and IABP were similar in comorbidities except for prior history of dialysis use (IABP 4, 8.2%; mLVAD 4, 50.0%; p < 0.01). The most common device related complication was hemolysis in 20 (31.3%) patients, more commonly in the mLVAD cohort (6, 75%) compared to the IABP group (8, 16.3%), p < 0.01. Bleeding (13, 20.3%) and infection (10, 15.6%) were less common with no significant difference between to the two groups. Stroke (2, 3%) and limb ischemia (1, 2%) were rare events overall. Twenty-seven patients (55.1%) in the IABP and one (12.5%) in the mLVAD cohort were free from complication, death, or emergent LVAD. Most patients were successfully bridged to transplant occurring in 57 (89%) patients, while 1 (2%) is currently waitlisted, and 6 (9%) were removed from the waitlist. Three patients expired while on device support and 4 required urgent implantation of a durable LVAD.
Conclusion:
TCS is a successful strategy to bridge patients to cardiac transplantation, but the burden of device related complications in this setting has not been well described. Our data demonstrates a significant risk of hemolysis, bleeding, and infection when using TCS as a bridge to transplant. While an overwhelming majority of patients are successfully transplanted, there are many that are either delisted or expire while on support, and even fewer who can be salvaged with a durable, implantable device. Consideration for organ allocation distribution to include temporary device adverse events in patients without a durable option as salvage therapy may be prudent to minimize waitlist death and removal.
Mechanical Support and Thoracic Transplantation Summit:
ECMO/Mechanical Support
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