title: Should patients 60 years and older undergo bridge to transplantation with continuous-flow left ventricular assist devices?
abstract: BACKGROUND
  Although left ventricular assist devices (LVADs) are now commonly used as a bridge to orthotopic heart transplantation (OHT), the upper patient age limit for this therapy has not been defined. Smaller studies have suggested that advanced age should not be a contraindication to bridge to transplantation (BTT) LVAD placement. The purpose of this study was to examine outcomes in patients 60 years and older undergoing BTT with continuous-flow LVADs.
  
  
  METHODS
  The United Network for Organ Sharing (UNOS) database was reviewed to identify first-time OHT recipients 60 years of age and older (2005-2010). Patients were stratified by preoperative support: continuous-flow LVAD, intravenous inotropic agents, and direct transplantation. Survival after OHT was modeled using the Kaplan-Meier method. All-cause mortality was examined using multivariable Cox proportional hazard regression.
  
  
  RESULTS
  Of 2,554 patients, 1,142 (44.7%) underwent direct transplantation, 264 (10.3%) had LVAD BTT, and 1,148 (45.0%) had BTT with inotropic agents. The mean age was 64±3 years, and 460 (18.0%) patients were women. Mean follow-up was 29±19 months. Survival differed significantly among the 3 groups. Patients with LVAD BTT had significantly lower survival after OHT compared with the other groups at 30 days and 1 year. This survival difference was no longer significant at 2 years after OHT or when deaths in the first 30 days were censored. LVAD BTT increased the hazard of death at 1 year by 50% (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.05-2.15; p=0.03), compared with patients who underwent direct transplantation.
  
  
  CONCLUSIONS
  This study represents the largest modern cohort in which survival after OHT has been evaluated in patients 60 years or older who received BTT. Older patients have lower short-term survival after OHT when BTT is carried out with a continuous-flow LVAD compared with inotropic agents or direct transplantation.
authors.affiliation: Department of Surgery, Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
authors.forename: Jeremiah G
authors.initials: JG
authors.lastname: Allen
authors.forename: Arman
authors.initials: A
authors.lastname: Kilic
authors.forename: Eric S
authors.initials: ES
authors.lastname: Weiss
authors.forename: George J
authors.initials: GJ
authors.lastname: Arnaoutakis
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: George
authors.forename: Ashish S
authors.initials: AS
authors.lastname: Shah
authors.forename: John V
authors.initials: JV
authors.lastname: Conte
mesh_terms: D002423:Cause of Death / Q000639:trends; D004867:Equipment Design; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation / Q000379:methods*; D006353:Heart-Assist Devices / Q000706:statistics & numerical data*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008396:Maryland / Q000453:epidemiology; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018570:Risk Assessment / Q000379:methods*; D013997:Time Factors; D014019:Tissue Donors / Q000600:supply & distribution*; D016896:Treatment Outcome; D014850:Waiting Lists