Right and left ventricular assist devices are an option for bridge to heart transplant - The 68th Annual Conference of the Israel Heart Society in association with the Israel Society of Cardiothoracic Surgery

Ronen Toledano ¹ Oliver K. Jawitz ^3,4 Jacob N. Schroder ³ Mani A. Daneshmand ³ Chetan B. Patel ⁵ Efrat Kurtzwald-Josefson ¹ J. Sam Meyer ^1,2 Dan Aravot ^1,2 Carmelo A. Milano ³ Yaron D. Barac ^1,2

¹Division of Cardiovascular and Thoracic Surgery, Rabin Medical Center, Israel
²Sackler Faculty of Medicine, Tel Aviv University, Israel
³Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, USA
⁴Duke Clinical Research Institute, Duke University Medical Center, USA
⁵Division of Cardiology, Department of Medicine, Duke University Medical Center, USA

Left Ventricular Assist Device (LVAD) patients with right ventricular (RV) dysfunction are prioritized on the heart transplant waitlist; however, their post-transplant survival is less well characterized. We aimed to determine whether pre-transplant RV dysfunction impacts post-operative survival in LVAD bridge-to-transplant (BTT) patients.

Retrospective review of the 2005-2018 OPTN/UNOS registry for candidates ≥ 18 years of age waitlisted for first-time isolated heart transplantation post LVAD implantation (n=5605).Candidates were stratified based upon having RV dysfunction defined as the need for RVAD or IV inotropes. Post-transplant survival was assessed.

450 patients with RV dysfunction - 344 LVAD and IV (intra venous) inotropes BTT, 106 LVAD and RVAD, and 5,155 LVAD BTT patients without the need for right side support. Compared with non-RV dysfunction patients, LVAD BTT patients with RV dysfunction were younger (51, 55 vs 56, p<0.001), and waited less time for organs (51, 93.5 vs 125 days, p<0.001). These patients also had longer post-transplant length of stay (18, 20 vs 16 days, p<0.001). RV dysfunction was not associated with decreased post-transplant survival on unadjusted Kaplan-Meier analysis (p=0.18), and neither pre-op RVAD nor IV inotropes independently predicted worse survival on multivariate Cox Proportional Hazards analysis (p=0.06, 0.98). However, pre-transplant liver dysfunction was an independent predictor of worse survival (HR 1.06, p<0.001), specifically in the LVAD group and not in the LVAD + RVAD/IV inotropes.

Pre-heart transplant RV failure in LVAD BTT patients is not associated with decreased post-transplant survival. Survival difference is driven primarily by pre-transplant liver dysfunction in LVAD patients lacking support to the RV. Patients with Bi-Ventricular failure are prioritized on the waitlist, as their critical pre-transplant condition does not impact their post-transplant survival. Therefore, surgeons should be encouraged to transplant these severely ill patients. Nevertheless, LVAD patients with liver dysfunction should be optimized pre-transplant to prevent long-term reduced survival.