on August 16, 2004
Published online before print August 16, 2004, doi: 10.1161/01.CIR.0000139862.48167.23
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Submitted on June 23, 2003
From Brigham and Women’s Hospital, Boston, Mass (L.W.S.); Department of Medicine, University of Minnesota, Minneapolis (L.W.M.); National Heart, Lung, and Blood Institute, Bethesda, Md (P.D.-N.); Columbia Presbyterian Medical Center, Heart Failure Center, New York, NY (D.D.A., D.M.); International Center for Health Outcomes and Innovation Research (InCHOIR), Columbia University, New York, NY (M.K.P., R.G.L.); IHC LDS Hospital Heart Failure Prevention and Treatment Program, Salt Lake City, Utah (D.G.R.); Heart Failure Treatment Program, University of Iowa Hospitals, Iowa City (R.M.O.); BryanLGH Heart Institute, Lincoln, Neb (S.K.K.); Midwest Heart Specialists, Edward Heart Hospital, Naperville, Ill (M.R.C.); and Wisconsin Heart and Vascular Clinics, Milwaukee (L.S.W.). * To whom correspondence should be addressed. E-mail: lstevenson{at}partners.org.
Background--Left ventricular assist devices (LVADs) have improved survival in patients with end-stage heart failure. Compared with previous trials, the Randomized Evaluation of Mechanical Assistance in Treatment of Chronic Heart Failure (REMATCH) trial enrolled patients with more advanced heart failure and high prevalence of intravenous inotropic therapy. This study analyzes, on a post hoc basis, outcomes in patients undergoing inotropic infusions at randomization. Methods and Results--Of 129 patients randomized, 91 were receiving intravenous inotropic therapy at randomization to LVAD or optimal medical management (OMM). Mean systolic pressure was 100 versus 107 mm Hg in those not receiving inotropes, serum sodium was 134 versus 137 mEq/L, and left ventricular ejection fraction was 17% for both groups. LVADs improved survival throughout follow-up for patients undergoing baseline inotropic infusions (P=0.0014); for the LVAD group versus the OMM group, respectively, 6-month survival was 60% versus 39%, 1-year survival rates were 49% versus 24%, and 2-year survival rates were 28% versus 11%. For 38 patients not undergoing inotropic infusions, 6-month survival was 61% for those with LVADs and 67% for those with OMM, whereas 1-year rates were 57% and 40%, respectively (P=0.55). Quality-of-life scores for survivors improved. Median days out of hospital for patients on inotropic therapy at randomization were 255 with LVAD and 105 with OMM. Conclusions--Despite severe compromise, patients undergoing inotropic infusions at randomization derived major LVAD survival benefit with improved quality of life. Patients not undergoing inotropic infusions had higher survival rates both with and without LVAD, but differences did not reach significance. Future studies should prespecify analyses of inotropic and other therapies to determine how disease severity and parallel medical treatment influence the benefits offered by mechanical circulatory support.
Revised on April 15, 2004
Accepted on April 19, 2004
Left Ventricular Assist Device as Destination for Patients Undergoing Intravenous Inotropic Therapy. A Subset Analysis From REMATCH (Randomized Evaluation of Mechanical Assistance in Treatment of Chronic Heart Failure)
Lynne Warner Stevenson MD*,
Key words: heart failure • transplantation • heart-assist device
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Circulation 2004 110: 893.
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