How does successful bridging with ventricular assist device affect cardiac transplantation outcome?

A best evidence topic in cardiac surgery was written according to a structured protocol. The issue was to determine the impact of bridge-to-transplant ventricular assist device support on survival after cardiac transplantation. Altogether 428 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The treatment options for patients with advanced heart failure or those with deteriorating end-organ function on maximal medical therapy are limited to intravenous inotropes and mechanical assistance with intra-aortic balloon pump (IABP) or ventricular assist device (VAD). Studies exploring the effect of VADs on post-transplant mortality have yielded conflicting results. The Registry of the International Society for Heart and Lung Transplantation continues to identify mechanical support as a risk factor for decreased survival after transplantation. A limitation of this report is that the multivariable adjustment uses variables recorded not at the time of device implant but at the time of transplant. Some of the recipient characteristics thus may be altered by the device implant. Compared with the previous reports the latest data show improvement in post-transplant survival in the recent era. In addition, the excess risk appears to be limited to the early post-transplant period. Experienced centers consistently report outstanding post-transplant results with left ventricular assist device (LVAD) bridging. Of the 12 papers seven showed no difference in survival, and five showed a reduced survival. In the papers showing no difference, one year survival averaged from 85% in supported patients to 87% in non-supported patients. In papers reporting a difference in outcome, one year averaged survival was 74% in LVAD recipients compared to 90% in non-bridged patients. Decreased survival is associated with patients suffering from dilated cardiomyopathy, transplanted within two weeks of LVAD implantation and bridged to transplantation before 2003 as opposed to patients transplanted more recently. Based on the available evidence we conclude that in selected patients survival after heart transplantation in patients bridged with VAD is comparable to those who did not receive the device.