TOP5: Heart Transplant versus LVADs: Is destination therapy the new goal?

Background: With improving survival of patients following acute coronary syndromes and chronic heart failure, more patients are reaching the end stage of illness requiring heart transplantation (HT) as a finalgoal therapy. Mechanical circulatory support (MCS) devices like the left ventricular assist device (LVAD) play a major role as destination therapy or bridging therapy for this patient demographic. The improvement of modern LVADs paired with the increase of life expectancy, and the underwhelming engagement of HT donation in the US, ponders on the suggestibility of redirecting efforts for destination or bridging therapy for a growing population. This study assesses the tendencies of LVAD use in comparison to those of HT performance, and analyses the direct correlation with one another as predictive values for future directives in the AHF population. Methods: National data from the Organ Procurement & Transplantation Network (OPTN) was retrieved for the use of LVADs, the performance of primary HT and re-do HT over the last 30 years. Upon data retrieval, descriptive statistics were identified for 6 different groups (ages 18-34, 35-49, 50-64, above 65 years, and the collective adult cohort) including annual growth rate, and comparison within the group means. A regression analysis was performed to determine the variable relationship between LVAD placement and performance of HT. Results: Since 1992, a total of 75098 HT, and 21041 LVAD placements have been performed in the US. There is a significant difference in the number of HT and LVAD placements performed (LVAD vs PT: p=0.0001; LVAD vs re-do HT: p=0.0001). However, upon regression analysis, 64% of LVAD placement determines the subsequent bridging to HT, and the annual growth rate of LVAD placement has a positive significant correlation with the relatively sustained number of HT performed yearly (Coefficient of 0.87; Confidence interval 95%, p=0.000). When comparing LVAD placement to primary HT performance and re-do HT, a significant increase will continue to occur based on the thus-far determined growth rate across all age groups (p= 0.0001). Thus, suggestive that within the upcoming years, the number of LVADs placed will equal the amount of HT performed. Conclusions: With the continuance in evolution and improvement of LVADs in the AHF population and the uneven number of HT performed, this study outlines that the growing tendencies of MCS should be prioritized in lieu of HT availability or strategies to increase donation culture. The prioritization of MCS should aim for a better and comprehensive understanding of the role of these devices and adequate management in a long-term basis.Figure 1. LVAD, primary transplant and transplant repeat annual growth rate