title: A prospective comparison of mid-term outcomes in patients treated with heart transplantation with advanced age donors versus left ventricular assist device implantation.
abstract: In Europe, the age of heart donors is constantly increasing. Ageing of heart donors limits the probability of success of heart transplantation (HTx). The aim of this study is to compare the outcome of patients with advanced heart failure (HF) treated with a continuous-flow left ventricular assist device (CF-LVAD) with indication as bridge to transplantation (BTT) or bridge to candidacy (BTC) versus recipients of HTx with the donor's age above 55 years (HTx with donors >55 years).
  
  
  
  we prospectively evaluated 301 consecutive patients with advanced HF treated with a CF-LVAD (n = 83) or HTx without prior bridging (n = 218) in our hospital from January 2006 to January 2015. We compared the outcome of CF-LVAD-BTT (n = 37) versus HTx with donors >55 years (n = 45) and the outcome of CF-LVAD-BTT plus BTC (n = 62) versus HTx with donors >55 years at the 1- and 2-year follow-up. Survival was evaluated according to the first operation.
  
  
  
  The perioperative (30-day) mortality rate was 0% in the LVAD-BTT group vs 20% (n = 9) in the HTx group with donors >55 years (P = 0.003). Perioperative mortality occurred in 5% of the LVAD-BTT/BTC patients (n = 3) and in 20% of the HTx with donors >55 year group (P = 0.026). Kaplan-Meier curves estimated a 2-year survival rate of 94.6% in CF-LVAD-BTT vs 68.9% in HTx with donors >55 years [age- and sex-adjusted hazard ratio (HR) 0.25; 95% confidence interval (CI) 0.08-0.81; P = 0.02 in favour of CF-LVAD]. Considering the post-HTx outcome, a trend in favour of CF-LVAD-BTT was also observed (age- and sex-adjusted HR 0.45; 95% CI 0.17-1.16; P = 0.09 in favour of CF-LVAD), whereas CF-LVAD-BTT/BTC showed a similar survival at 2 years compared with HTx with donors >55 years, both censoring the follow-up at the time of HTx and considering the post-HTx outcome.
  
  
  
  Early and mid-term outcomes of patients treated with a CF-LVAD with BTT indication seem better than HTx with old donors. It must be emphasized that up to 19% of patients in the CF-LVAD/BTT group underwent transplantation in an urgent condition due to complications related to the LVAD. At the 2-year follow-up, CF-LVAD with BTT and BTC indications have similar outcome than HTx using old heart donors. These results must be confirmed in a larger and multicentre population and extending the follow-up.
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy enrico.ammirati@ospedaleniguarda.it.
authors.forename: Enrico
authors.initials: E
authors.lastname: Ammirati
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Manlio G
authors.initials: MG
authors.lastname: Cipriani
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Marisa
authors.initials: M
authors.lastname: Varrenti
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Tiziano
authors.initials: T
authors.lastname: Colombo
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Garascia
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Aldo
authors.initials: A
authors.lastname: Cannata
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Giovanna
authors.initials: G
authors.lastname: Pedrazzini
authors.affiliation: Coordinamento trapianti North Italy Transplantation program (NITp), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
authors.forename: Elena
authors.initials: E
authors.lastname: Benazzi
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Filippo
authors.initials: F
authors.lastname: Milazzo
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Oliva
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Maria P
authors.initials: MP
authors.lastname: Gagliardone
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Claudio F
authors.initials: CF
authors.lastname: Russo
authors.affiliation: 'De Gasperis' Cardio Center, Niguarda Ca' Granda Hospital, Milan, Italy.
authors.forename: Maria
authors.initials: M
authors.lastname: Frigerio
mesh_terms: D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000503:physiopathology / Q000601:surgery*; D016027:Heart Transplantation / Q000379:methods*; D006353:Heart-Assist Devices / Q000009:adverse effects; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D014019:Tissue Donors; D016896:Treatment Outcome
keywords: Advanced heart failure; Age; Heart transplantation; Left ventricular assist device; Marginal donor