title: Comparison of early versus delayed timing of left ventricular assist device implantation as a bridge-to-transplantation: An analysis of the UNOS dataset.
abstract: BACKGROUND
  Placement of left ventricular assist devices (LVAD) as a bridge-to-heart transplantation (HTx) has rapidly expanded due to organ donor shortage. However, the timing of LVAD implantation is variable and it remains unclear if earlier implantation improves survival.
  
  
  METHODS
  We analyzed 14,187 adult candidates from the United Network of Organ Sharing database. Patients were classified by 3 treatment strategies including patients medically treated alone (MED, n=11,009), patients on LVAD support at listing (Early-LVAD, n=1588) and patients undergoing LVAD placement while awaiting HTx (Delayed-LVAD, n=1590). Likelihood of HTx and event-free survival were assessed in patients subcategorized by clinical strategies and UNOS status at listing.
  
  
  RESULTS
  The device support strategy, despite the timing of placement, was not associated with increased likelihood of HTx compared to MED group. However, both LVAD implantation strategies showed better survival compared to MED group (Early-LVAD: HR 0.811 and 0.633, 95% CI 0.668-0.984 and 0.507-0.789, for 1A and 1B; p=0.034 and p<0.001, Delayed-LVAD: HR 0.553 and 0.696, 95% CI 0.415-0.736 and 0.571-0.847, for 1A and 1B; both p<0.001, respectively). Furthermore, there was no significant difference in survival between these LVAD implantation strategies in patients listed as 1B (p=0.500), although Early-LVAD implantation showed worse survival in patients listed as 1A (HR 1.467, 95% CI 1.076-2.000; p=0.015).
  
  
  CONCLUSIONS
  LVAD support strategies offer a safe bridge-to-HTx. Those candidates who receive urgent upfront LVAD implantation for HTx, and improve to 1B status, would achieve competitive survival with those who receive elective LVAD implantation.
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA.
authors.forename: Shuichi
authors.initials: S
authors.lastname: Kitada
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA.
authors.forename: P Christian
authors.initials: PC
authors.lastname: Schulze
authors.affiliation: Department of Biostatistics, Mailman School of Public Health, Columbia University Medical Center, New York, New York, USA.
authors.forename: Zhezhen
authors.initials: Z
authors.lastname: Jin
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA.
authors.forename: Kevin
authors.initials: K
authors.lastname: Clerkin
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA.
authors.forename: Shunichi
authors.initials: S
authors.lastname: Homma
authors.affiliation: Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, New York, USA.
authors.forename: Donna M
authors.initials: DM
authors.lastname: Mancini
mesh_terms: D000328:Adult; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006333:Heart Failure / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology; D014850:Waiting Lists
keywords: Heart failure; Heart transplantation; LVAD