Cardiac Transplantation in the VAD Era: Twenty-Year Experience of a Single Center

Objectives: Cardiac transplantation remains the gold standard for treatment of end stage heart failure. During the past two decades, ventricular assist devices (VADs) have notably contributed to cardiac transplantation as bridge to transplant therapy (BTT). However, this new strategy has also produced a different recipient landscape with higher surgical complexity. Thus, the purpose of this study was to elucidate the outcomes of cardiac transplantation in VAD patients and compare them to non-previously operated patients.

Methods: We reviewed the outcome of 449 end-stage heart failure patients who underwent cardiac transplantation in our institution between 1997 and 2017. Patients were divided into two groups: group A (previous VAD-implantation; n = 124) and group B (controls; n = 325).

Results: All continuous data are summarized as mean ± standard deviation (SD). Demographical data: 48.5% male, age (y) 48.5 ± 15.1, dilative cardiomyopathy (DCM) 52.9%; ischemic cardiomyopathy (ICM) 31.4%. VAD implantations started in 1998 (HVAD 38.7%, HeartMate II 38.7%, HeartMate XVE 19.4%, PVAD 2.4%, EXCOR 2.4%, HeartMate 31.6%, Circulite 1.6%, HeartAssist 50.8%). Group A patients showed higher incidence of high urgency (HU) status (91% versus 51.4%; p < 0.001), with longer waiting times (Group A: 632 ± 900d versus Group B: 265 ± 402d; p < 0.001). Total ischemia time was higher in Group A patients (243 ± 68 minute. versus 198 ± 43 minute; p < 0.001). Cardiac transplantation developed from mostly non-previously operated patients with normal allocation status toward predominantly HU-status patients with previous VAD surgery over the observation period. Survival rates were very similar (Group A vs. Group B): 30 days (87.1 vs. 87.2%; p = 0.89), 90 days (85.2 vs. 85.1%; p = 0.92), year (78.5 vs. 80.1%; p = 0.73) and 5 years (69.4 vs. 69.9%; p = 0.83).

Conclusion: Our data show that despite the increase of surgical complexity, overall survival rates are without statistical differences between recipients with previous VAD implants and those without. However, increased ischemia times in BTT patients represent a major challenge in modern heart transplantation surgery. In this context, new concepts of organ preservation might be an important contribution to increase organ availability and surgical safety.