LVAD Complications Causing High-Urgent Status on Waiting List: Impact on Outcome after Heart Transplantation

Objectives: For heart transplantation (htx) a new scoring system which considers a potential postoperative benefit is scheduled for the near future. Therefore it is important to regard the impact of different clinical settings in high-urgent (HU) listed patients with left ventricular assist devices (LVAD) after htx. In our patients, we aimed to analyze HU-LVAD-patients after cardiac transplant, particularly with regard to the clinical conditions causing HU-status.

Methods: Between 2010 and July 2018, a total of 108 patients underwent htx in our department. 69 of these patients were supported by an LVAD before transplant and 35 of those were transplanted with HU status, 34 with status “T.” With regard to the HU-causing complications the LVAD-HU group could be divided into 6 groups: Group HU1 suffered from severe LVAD-infections, HU2 from thromboembolic events and HU3 from neurological complications. Right heart failure, severe cardiac arrhythmias and intractable gastrointestinal bleeding were the reasons for HU-listing in HU4, HU5 and HU6, respectively. LVAD-patients which were transplanted electively (group T) served as controls.

Results: The subgroups HU1 to HU6 consisted of 13, 7, 6, 5, 3, and 1 patients, respectively. Thirty-day mortality was 14.7% in group T and 17.1% in group HU, with 33.3 and 28.6% in groups HU5 and HU2, respectively. Extracorporeal life support (ECLS) was applied in 23.5% in group T, whereas 42.9% of HU patients needed perioperative ECLS, p = 0.065, with the highest incidence in HU5 and HU1 with 66.7 and 46.2%. Duration of intubation, postoperative stay on ICU and in hospital was significantly prolonged in group HU1 compared to all other HU patients and by trend to group T. Severe postoperative infections occurred in 14.7% of group T, compared to 21.2% in all HU patients (p > 0.05), as expected most frequent in HU1 with 53.8% (p < 0.05). No significant differences were found regarding further postoperative morbidity. One-year-survival was 69% in group T compared to 64% in all HU-LVAD patients. Again, we found the worst outcome for group HU1 with 28.6% (p < 0.05 to all other HU patients).

Conclusions: With our single-center experience we could show that the outcome of HU-listed LVAD-patients after htx is significantly different with regard to the underlying complication while on LVAD. Patients with severe LVAD infections displayed the worst short- and midterm outcome after htx. This fact should be considered in preparation of the new benefit-allocation score.