Institutional volume of heart transplantation with left ventricular assist device explantation influences graft survival

J Heart Lung Transplant. 2014 Sep;33(9):931-6. doi: 10.1016/j.healun.2014.04.016. Epub 2014 May 15.

Abstract

Background: There are increasing numbers of patients undergoing orthotopic heart transplantation (OHT) with left ventricular assist device (LVAD) explantation (LVAD explant-OHT). We hypothesized that LVAD explant-OHT is a more challenging surgical procedure compared to OHT without LVAD explantation and that institutional LVAD explant-OHT procedural volume would be associated with post-transplant graft survival. We sought to assess the impact of institutional volume of LVAD explant-OHT on post-transplant graft survival.

Methods: This is a retrospective analysis of the Scientific Registry of Transplant Recipients for adult OHTs with long-term LVAD explantation. LVAD explant-OHT volume was characterized on the basis of the center's year-specific total OHT volume (OHTvol) and year-specific LVAD explant-OHT volume quartile (LVADvolQ). The effect of LVADvolQ on graft survival (death or re-transplantation) was analyzed.

Results: From 2004 to 2011, 2,681 patients underwent OHT with LVAD explantation (740 with HeartMate XVE, 1,877 with HeartMate II and 64 with HeartWare devices). LVAD explant-OHT at centers falling in the lowest LVADvolQ was associated with reduced post-transplant graft survival (p = 0.022). After adjusting for annualized OHTvol (HR = 0.998, 95% CI 0.993 to 1.003, p = 0.515 and pulsatile XVE (HR = 0.842, 95% CI 0.688 to 1.032, p = 0.098), multivariate analysis confirmed a significantly (approximately 37%) increased risk of post-transplant graft failure among explant-OHT procedures occurring at centers in the lowest volume quartile (HR = 1.371, 95% CI 1.030 to 1.825, p = 0.030).

Conclusion: Graft survival is decreased when performed at centers falling in the lowest quartile of LVAD explant-OHT for a given year. This volume-survival relationship should be considered in the context of limited donor organ availability and the rapidly growing number of LVAD centers.

Keywords: heart transplantation; left ventricular assist device; transplant center volume.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Device Removal
  • Female
  • Graft Rejection / epidemiology
  • Graft Survival
  • Heart Failure / mortality
  • Heart Failure / surgery*
  • Heart Transplantation*
  • Heart-Assist Devices*
  • Hospitals, Low-Volume / statistics & numerical data*
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Registries
  • Retrospective Studies
  • Survival Rate
  • Treatment Outcome
  • Ventricular Dysfunction, Left / mortality
  • Ventricular Dysfunction, Left / surgery*
  • Young Adult