Long Term Left Ventricular Assist Device as Bridge to Heart Transplantation: De Facto Destination Therapy in Many?

Background: Left ventricular assist devices (LVAD) are increasingly used as bridge to transplant (BTT) for patients with advanced congestive heart failure (CHF). After LVAD implantation, patients' UNOS status is permanently updated to 1B. Patients may also be upgraded to 1A for a total of 30 days at the clinicians' discretion and/or permanently if a device complication occurs. The aim of this study was to evaluate the UNOS status of patients on LVAD support at the time of transplantation and to determine the reasons for status changes. Methods: A retrospective chart review was performed of all patients who received long term BTT LVADs between 1/2001-2/2010 at a large transplant center. Results: 224 LVAD BTT patients were identified. 180 (80.4%) were males, mean age was 51.9 ± 12.6 years. Over a follow-up period of X + -y years, 166 (74.1%) BTT patients were transplanted, 25 (11.2%) are still listed, while 33 (14.7%) patients were de-listed due to mortality or advanced co-morbidity. Mean time from LVAD implantation to transplant was 166.6 ± 164.1 days. Only 44 patients were transplanted as UNOS 1B, while 122 were transplanted as UNOS 1A. Of these 122, 70 patients were transplanted during their 30 days 1 A grace period and 52 patients after upgrading to UNOS 1A due to device complication or malfunction. There was a higher proportion of transplanted 1A patients versus transplanted 1B patients that were blood type O. Conclusions: After utilizing the initial 30 day 1A grace period, many LVAD BTT patients (particularly those with blood type 0) are unlikely to be transplanted unless they experience a device complication justifying device upgrade their UNOS status to 1A. As device technology improves and complication rates fall, many of these patients will have de facto destination therapy.