Ventricular assist devices and aggressive immunosuppression: looking beyond overall survival.
BACKGROUND
Patients bridged to heart transplantation with a ventricular assist device (VAD) developed coronary vasculopathy at the same rate as non-bridged patients despite having higher levels of pre-formed antibodies. We hypothesized that allosensitized VAD patients have higher levels of immunosuppression and thus different morbidity and causes of mortality.


METHODS
Patients who received a transplant between January 1996 and May 2002 were separated into 2 groups based on the need for VAD support as a bridge to transplantation. Transplant and Inpatient Pharmacy Databases and charts were queried for date of transplantation, degree of allosensitization, use of desensitization therapy, immunosuppressive strategies, number of treated rejection episodes, and specific causes of death.


RESULTS
This study investigated 238 patients (125 VAD patients, 113 non-VAD patients). VAD patients were more likely to be allosensitized than non-VAD patients (20% vs 5%, p < 0.01). OKT3 was given to 22% of VAD patients as anti-rejection prophylaxis and 14% received pre-transplant plasmapheresis. Non-VAD patients rarely were desensitized (2.6% of non-VAD patients). After transplantation, 68 VAD patients (54%) and 44 non-VAD patients (39%) had episodes of severe rejection requiring therapy. Episodes of rejection in VAD patients were commonly treated with steroids (90%), plasmapheresis (10%), and OKT3 (7%), and episodes of rejection in non-VAD patients were treated with steroids (76%) and OKT3 (8%). The 5-year survival for both groups was similar (90% and 86% respectively, p = 0.31). VAD patients commonly died of sepsis (75%), and non-VAD patients died of rejection (39%) and ischemic transplant cardiomyopathy (30%).


CONCLUSIONS
When short-term outcomes between bridged and non-bridged heart transplant recipients were compared, overall survival was similar but causes of death differed. Findings in this study might aid in the post-operative management of patients bridged to transplantation with a VAD.
Gonzalez-Stawinski
Gonzalo V
GV
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio 44121, USA. gonzalg@ccf.org
Cook
Daniel J
DJ
Chang
Albert S Y
AS
Banbury
Michael K
MK
Navia
Jose L
JL
Hoercher
Katherine
K
Lober
Cheryl
C
Atik
Fernando A
FA
Taylor
David O
DO
Yamani
Mohamed H
MH
Young
James B
JB
Starling
Randall C
RC
Smedira
Nicholas G
NG
D000368:Aged; D000961:Antilymphocyte Serum / Q000008:administration & dosage / Q000627:therapeutic use*; D002423:Cause of Death; D003327:Coronary Disease / Q000276:immunology / Q000517:prevention & control / Q000601:surgery; D005260:Female; D006084:Graft Rejection / Q000188:drug therapy; D016027:Heart Transplantation / Q000276:immunology* / Q000401:mortality; D006353:Heart-Assist Devices; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D008297:Male; D008775:Methylprednisolone / Q000627:therapeutic use; D008875:Middle Aged; D016853:Muromonab-CD3 / Q000627:therapeutic use*; D010446:Peptide Fragments; D010956:Plasmapheresis; D012189:Retrospective Studies; D018805:Sepsis / Q000453:epidemiology; D013601:T-Lymphocytes / Q000276:immunology
D000961:Antilymphocyte Serum; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D016853:Muromonab-CD3; D010446:Peptide Fragments; C111242:thrombin receptor peptide (1-41); D008775:Methylprednisolone