Outcomes of left ventricular assist device implantation as destination therapy in the post-REMATCH era: implications for patient selection.
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.


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.
Lietz
Katherine
K
Cardiovascular Division, University of Minnesota, Minneapolis, USA. KL2384@columbia.edu
Long
James W
JW
Kfoury
Abdallah G
AG
Slaughter
Mark S
MS
Silver
Marc A
MA
Milano
Carmelo A
CA
Rogers
Joseph G
JG
Naka
Yoshifumi
Y
Mancini
Donna
D
Miller
Leslie W
LW
D000368:Aged; D002317:Cardiovascular Agents / Q000627:therapeutic use; D002423:Cause of Death; D004868:Equipment Failure / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation; D006353:Heart-Assist Devices / Q000706:statistics & numerical data; D006402:Hematologic Diseases / Q000150:complications; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D044342:Malnutrition / Q000150:complications; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology / Q000401:mortality; D011788:Quality of Life; D012042:Registries / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012306:Risk; D018805:Sepsis / Q000209:etiology / Q000401:mortality; D016019:Survival Analysis; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D018497:Ventricular Dysfunction, Right / Q000209:etiology / Q000401:mortality
D002317:Cardiovascular Agents