Emergent mechanical support in the community: improvement with early transplant center referral.

Emergent mechanical support for the failing ventricle, with eventual transfer for definitive care, is often required at non-transplant centers. Transfer for definitive care, in terms of bridge to transplant, may require ventricular assist device (VAD) placement at the primary institution or at the transplant center. Review of consecutive single transplant center referrals was conducted to decipher optimal management. From January 1997 to December 2000, 104 patients were transferred to the University of Pennsylvania Heart Failure/Transplant Service. Most were transferred from active cardiac surgical programs, with 56 patients having post-cardiotomy failure at the primary site. A VAD was placed in procedures done at the outside hospital (OSH) in 28 patients, most commonly (60%) an Abiomed device. Of the 76 patients that received a VAD at the transplant center (TxpC), 86% received a TCI or Thoratec device. Biventricular support was required in 34 patients. Overall survival was 57%, with 54 patients bridged to transplantation and 5 patients undergoing recovery. Patients having a VAD placed at the OSH had a 32% (9 of 28) survival, whereas at the TxpC survival was 65% (45 of 76) (p < 0.05). Mid-term follow-up showed that all 5 patients weaned are presently alive, and 52 patients are alive at >1-year post-transplant. The most common cause of death was multi-system organ failure (19 of 45), followed by major neurologic event (15 of 45). Infection was the cause of death in only 6 patients. Left ventricular failure can be treated by emergent VAD placement. Overall survival is substantial if these patients are referred to a transplant center with multiple options. In contrast to previous reports, survival rates may be improved by earlier referral, before VAD placement at non-transplant centers and use of a VAD with longer-term capability.