Published online before print July 16, 2007, doi: 10.1161/CIRCULATIONAHA.107.691972
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(Circulation. 2007;116:497-505.)
© 2007 American Heart Association, Inc.
Heart Failure |
Outcomes of Left Ventricular Assist Device Implantation as Destination Therapy in the Post-REMATCH Era
Implications for Patient Selection
From the Cardiovascular and Cardiothoracic Divisions of University of Minnesota, Minneapolis (K.L., L.W.M.); Georgetown University–Washington Hospital Center, Washington, DC (K.L., L.W.M.); LDS Hospital, Salt Late City, Utah (J.W.L., A.G.K.); Advocate Christ Medical Center, Oak Lawn, Ill (M.S.S., M.A.S.); Duke University Medical Center, Durham, NC (C.A.M., J.G.R.); and Columbia-Presbyterian Medical Center, New York, NY (Y.N., D.M.). Dr Lietz is now affiliated with the Division of Cardiology, Columbia-Presbyterian Medical Center, New York, NY.
Correspondence to Katherine Lietz, MD, PhD, Center for Advanced Cardiac Care, Division of Cardiology, Columbia-Presbyterian Medical Center, PH-12 Stem Rm 134, 622 W 168th St, New York, NY 10032. E-mail KL2384{at}columbia.edu
Received January 25, 2007; revision received May 8, 2007.
Background— The landmark Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial first demonstrated that implantation of left ventricular assist devices (LVADs) as destination therapy (DT) can provide survival superior to any known medical treatment in patients with end-stage heart failure who are ineligible for transplantation. In the present study, we describe outcomes of DT in the post-REMATCH era in the United States.
Methods and Results— The present study included 280 patients who underwent HeartMate XVE LVAD implantation between November 2001 and December 2005. A preoperative risk score for in-hospital mortality after LVAD implantation was established in 222 patients with complete data. All patients were followed up until death or December 2006. The 1-year survival after LVAD implantation was 56%. The in-hospital mortality after LVAD surgery was 27%. The main causes of death included sepsis, right heart failure, and multiorgan failure. The most important determinants of in-hospital mortality were poor nutrition, hematological abnormalities, markers of end-organ or right ventricular dysfunction, and lack of inotropic support. Stratification of DT candidates into low (n=65), medium (n=111), high (n=28), and very high (n=18) risk on the basis of the risk score calculated from these predictors corresponded with 1-year survival rates of 81%, 62%, 28%, and 11%, respectively.
Conclusions— Appropriate selection of candidates and timing of LVAD implantation are critical for improved outcomes of DT. Patients with advanced heart failure who are referred for DT before major complications of heart failure develop have the best chance of achieving an excellent 1-year survival with LVAD therapy.
CLINICAL PERSPECTIVE
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