Worse postoperative outcomes for critically ill patients bridged to urgent heart transplantation with VADs than with conventional therapy.

Spanish investigators led by Drs. Eduardo Barge-Caballero and Marisa Crespo-Leiro from the Hospital Universitario A Coruña conducted a multi-institutional retrospective study of 704 patients with critical heart failure, who underwent urgent, high-priority heart transplantation in 15 Spanish hospitals from January, 2000 to December, 2009. One hundred and seven patients had been supported with short-term VADs before transplantation, while the remaining 597 had been bridged with conventional therapy, that included intravenous inotropes, invasive mechanical ventilation and / or intraaortic balloon pump. Implanted VADs were paracorporeal pulsatile-flow devices in 58 cases and extracorporeal continuous-flow ones in 47. Interestingly, mean waiting list time was extremely short, around 5 days, a characteristic fact of the well-organized Spanish high-emergency organ procurement and allocation system.

Despite fairly similar pre-transplant clinical status and end-organ function, VAD bridged patients showed a higher incidence of severe surgical bleeding, longer bypass times and higher rates of primary graft failure than conventionally bridged patients, so as resulting in a significantly reduced post-transplant survival.

In Dr. Barge-Caballero´s opinion, “our data suggest that routine short-term VAD implantation in stable patients awaiting high-emergency heart transplantation should not be recommended, at least in countries with expected short waiting list times, as this strategy might compromise heart transplant outcomes”. For the main investigator of the study, “short-term VAD support as a bridge to high-emergency heart transplantation should be reserved for critically ill patients with a deteriorating haemodynamic status, in which conventional therapy is not enough to ensure adequate peripheral perfusion and to avoid irreversible end-organ damage”.