Abstract 15851: “Bridge to Decision” before Continuous-Flow Left Ventricular Assist Device Implantation: Bridge to Where Exactly?
Introduction: Because of patient condition, temporary circulatory support (TCS) is sometimes needed as a “bridge to decision” (BTD) before implantation of long-term implantable ventricular assist device (VAD). Because few data exist regarding long-term outcome, we present our experience with these BTD patients and compare outcomes with those undergoing direct LVAD implant (DL). Patients and
Methods: Of 342 pt undergoing HeartMate II®(Thoratec, Pleasanton, CA) implant at our institutions from January 2004 to January 2012, 25 (7.3%) pt (57±8 years, 64% male) needed TCS before implant (BTD cohort). Acute cardiac failure (72%) was the most common indication, with 96% in INTERMACS category I. Devices used as BTD included TandemHeart® in 20 pt, Impella® in 3, and extracorporeal membrane oxygenation (ECMO) in 2 pts. Median TCS support before VAD implant was 4 days (range, 3-7). In the BTD group, indication for VAD implant was bridge to transplant (BTT) in 19/25(76%).
Results: After VAD implant, compared with DL cohort, delayed sternal closure was more common in the BTD cohort (88% vs. 60%, p=0.007). Postop need for dialysis was significantly higher in the BTD group (16% vs. 4%, p=0.04), while right ventricular failure was similar (4% vs. 2%, p=0.48). The median length of ICU (16 vs. 7 days, p<0.001) and total hospital stay (37 vs. 22 days; p=0.0007) was significantly longer in the BTD cohort. Early (8% vs. 3%; p=0.30) and 90-day mortality (12% vs. 5%; p=0.17) was statistically similar. Late neurological events (4% vs. 5 %, p=1.00), pump-related hemolysis (8% vs. 5%, p=0.58) and driveline infection (4% vs. 6%, p=1.00) were similar in the BTD and DL groups, respectively. Survival at 2 years was 71% and 77% for the BTD and DL cohorts, respectively (p=0.19). Importantly, for BTT pt in the entire cohort, those in the BTD group were less likely to proceed to heart transplantation [HR: 2 (1, 9), p=0.04].
Conclusion: Despite a longer hospital stay, higher need for postop dialysis and fewer BTT pt progressing to undergo heart transplantation, early and late survival along with a similar late morbidity profile can be achieved when TCS is needed as a bridge prior to VAD implant.
- © 2012 by American Heart Association, Inc.