Elsevier

Transplantation Proceedings

Volume 48, Issue 1, January–February 2016, Pages 158-166
Transplantation Proceedings

Recent Advances in Transplantation
Thoracic transplantation
Adult Heart Transplantation Following Ventricular Assist Device Implantation: Early and Late Outcomes

https://doi.org/10.1016/j.transproceed.2015.12.007Get rights and content

Highlights

  • The impact of prior implantation of a VAD on short- and long-term post-operative outcomes of adult HTx was investigated.

  • In transplant recipients with prior cardiac surgery, recipients with a prior VAD had a longer intraoperative pump time and more blood product use when compared with transplant recipients with prior non-VAD cardiac surgery. Postoperative creatinine levels at peak and at discharge were similar between both recipient groups. Length of ICU and hospital stays was similar between both groups as well. Transplant recipients with prior VAD had a higher frequency of prolonged ventilation, in-hospital infections, and sternal wound infections, but not postdischarge infections, when compared with transplant recipients with prior non-VAD operations. In addition, the frequency of patients with reoperation for chest bleeding, dialysis, pneumonia, pneumothorax, abdominal surgery for mesenteric ischemia, sepsis, and pacemaker placement was similar between both groups.

  • Survival at 60 days was lower in the VAD group compared with the Non-VAD group. Nevertheless, 1-, 2-, 5-, 10-, and 12-year survival rates were not statistically different between transplant recipients in both groups. Cox analysis showed that pretransplantation VAD implantation did not account for an additional mortality risk at 12 years following transplantation, but was found to be a risk factor only for 60-day mortality post-transplantation. In comparison with other types of prior cardiac surgery, VAD implantation was not associated with increased long-term mortality risk after subsequent HTx.

Abstract

Purpose

The impact of prior implantation of a ventricular assist device (VAD) on short- and long-term postoperative outcomes of adult heart transplantation (HTx) was investigated.

Methods

Of the 359 adults with prior cardiac surgery who underwent HTx from December 1988 to June 2012 at our institution, 90 had prior VAD and 269 had other (non-VAD) prior cardiac surgery.

Results

The VAD group had a lower 60-day survival when compared with the Non-VAD group (91.1% ± 3.0% vs 96.6% ± 1.1%; P = .03). However, the VAD and Non-VAD groups had similar survivals at 1 year (87.4% ± 3.6% vs 90.5% ± 1.8%; P = .33), 2 years (83.2% ± 4.2% vs 88.1% ± 2.0%; P = .21), 5 years (75.7% ± 5.6% vs 74.6% ± 2.9%; P = .63), 10 years (38.5% ± 10.8% vs 47.6% ± 3.9%; P = .33), and 12 years (28.9% ± 11.6% vs 39.0% ± 4.0%; P = .36). The VAD group had longer pump time and more intraoperative blood use when compared with the Non-VAD group (P < .0001 for both). Postoperatively, VAD patients had higher frequencies of >48-hour ventilation and in-hospital infections (P = .0007 and .002, respectively). In addition, more VAD patients had sternal wound infections when compared with Non-VAD patients (8/90 [8.9%] vs 5/269 [1.9%]; P = .005). Both groups had similar lengths of intensive care unit (ICU) and hospital stays and no differences in the frequencies of reoperation for chest bleeding, dialysis, and postdischarge infections (P = .19, .70, .34, .67, and .21, respectively). Postoperative creatinine levels at peak and at discharge did not differ between the 2 groups (P = .51 and P = .098, respectively). In a Cox model, only preoperative creatinine ≥1.5 mg/dL (P = .006) and intraoperative pump time ≥210 minutes (P = .022) were individually considered as significant predictors of mortality within 12 years post-HTx. Adjusting for both, pre-HTx VAD implantation was not a predictor of mortality within 12 years post-HTx (hazard ratio [HR], 1.23; 95% confidence interval [CI], 0.77–1.97; P = .38). However, pre-HTx VAD implantation was a risk factor for 60-day mortality (HR, 2.86; 95% CI, 1.07–7.62; P = .036) along with preoperative creatinine level ≥2 mg/dL (P = .0006).

Conclusions

HTx patients with prior VAD had lower 60-day survival, higher intraoperative blood use, and greater frequency of postoperative in-hospital infections when compared with HTx patients with prior Non-VAD cardiac surgery. VAD implantation prior to HTx did not have an additional negative impact on long-term morbidity and survival following HTx. Long-term (1-, 2-, 5-, 10-, and 12-year) survival did not differ significantly in HTx patients with prior VAD or non-VAD cardiac surgery.

Section snippets

Patients

From December 1988 to June 2012, our center performed 704 adult orthotopic heart transplantation (OHT) procedures, excluding multiple-organ and redo-cardiac transplantations; there were 345 (49.0%) recipients without prior sternotomy and 359 (51.0%) recipients with 1 or more prior sternotomies. To analyze the effect of VAD implantation prior to HTx, we divided the 359 recipients with prior sternotomies into 2 groups: HTx patients with a history of VAD implantation (VAD group, n = 90) and HTx

Preoperative Characteristics

Table 1 shows the baseline characteristics of the HTx patients in the VAD and Non-VAD groups and their organ donors. Recipients in the VAD group were younger on average at the time of HTx (P < .0001). They also had higher weight and body mass index (BMI) compared with recipients in the Non-VAD group (P = .003 and P = .023, respectively). However, donor-to-recipient weight ratio was similar between HTx patients in both groups (P = .71). The distribution of gender was similar between both groups

Preoperative Characteristics

HTx patients with prior VAD were younger on average compared with those with no prior VAD (Table 1), similar to observations in other studies [20], [21], [22], [23]. However, Drakos et al showed similar average ages between both groups, but it should be noted that only 14.5% of recipients in the No-MCS group had previous cardiac surgery, whereas all of our study patients had at least 1 previous cardiac surgery [24]. We tended to use larger donors for HTx patients with prior VAD (Table 1)

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