Outcomes with ambulatory advanced heart failure from the Medical Arm of Mechanically Assisted Circulatory Support (MedaMACS) Registry

JOURNAL OF HEART AND LUNG TRANSPLANTATION

卷:38

Article

Ambardekar, Amrut, V¹  Kittleson, Michelle M.²  Palardy, Maryse³  Mountis, Maria M.⁴  Forde-McLean, Rhondalyn C.⁵  DeVore, Adam D.^6,7  Pamboukian, Salpy, V¹⁵  Thibodeau, Jennifer T.⁸  Teuteberg, Jeffrey J.⁹  Cadaret, Linda¹⁰  Xie, Rongbing¹¹  Taddei-Peters, Wendy¹²  Naftel, David C.¹⁰  Kirklin, James K.¹⁰  Stevenson, Lynne W.¹³  Stewart, Garrick C.¹⁴ 

[1] Univ Colorado, Div Cardiol, Dept Med, Aurora, CO 80045 USA

[2] Cedars Sinai Med Ctr, Smidt Heart Inst, Los Angeles, CA 90048 USA

[3] Univ Michigan, Dept Internal Med Cardiovasc, Ann Arbor, MI 48109 USA

[4] Cleveland Clin, Div Cardiovasc Med, Cleveland, OH 44106 USA

[5] Univ Penn, Dept Med, Philadelphia, PA 19104 USA

[6] Duke Univ, Med Sch, Div Cardiol, Durham, NC USA

[7] Duke Univ, Duke Clin Res Inst, Med Sch, Durham, NC USA

[8] Univ Texas Southwestern, Dept Internal Med Cardiol, Birmingham, AL USA

[9] Stanford Univ, Dept Med, Div Cardiovasc Med, Stanford, CA 94305 USA

[10] Univ Iowa, Dept Internal Med, Div Cardiol, Iowa City, IA 52242 USA

[11] Univ Alabama Birmingham, Dept Surg, Birmingham, AL 35294 USA

[12] NHLBI, Div Cardiovasc Dis, Adv Technol & Surg Branch, Bldg 10, Bethesda, MD 20892 USA

[13] Vanderbilt Univ, Dept Med, Div Cardiovasc Med, Nashville, TN USA

[14] Brigham & Womens Hosp, Div Cardiovasc Med, 75 Francis St, Boston, MA 02115 USA

[15] Univ Alabama Birmingham, Div Cardiovasc Sci, Birmingham, AL USA

关键词: mechanical circulatory support;    ventricular assist device;    cardiac transplantation;    advanced heart failure;    patient decision-making;   

DOI  :  10.1016/j.healun.2018.09.021

来源: Elsevier

【 摘 要 】

BACKGROUND: The outlook for ambulatory patients with advanced heart failure (HF) and the appropriate timing for left ventricular assist device (LVAD) or transplant remain uncertain. The aim of this study was to better understand disease trajectory and rates of progression to subsequent LVAD therapy and transplant in ambulatory advanced HF. METHODS: Patients with advanced HF who were New York Heart Association (NYHA) Class III or IV and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Profiles 4 to 7, despite optimal medical therapy (without inotropic therapy), were enrolled across 11 centers and followed for the end-points of survival, transplantation, LVAD placement, and health-related quality of life. A secondary intention-to-treat survival analysis compared outcomes for MedaMACS patients with a matched group of Profile 4 to 7 patients with LVADs from the INTERMACS registry. RESULTS: Between May 2013 and October 2015, 161 patients were enrolled with INTERMACS Profiles 4 (12%), 5 (32%), 6 (49%), and 7 (7%). By 2 years after enrollment, 75 (47%) patients had reached a primary end-point with 39 (24%) deaths, 17 (11%) undergoing LVAD implantation, and 19 (12%) receiving a transplant. Compared with 1,753 patients with Profiles 4 to 7 receiving LVAD therapy, there was no overall difference in intention-to-treat survival between medical and LVAD therapy, but survival with LVAD therapy was superior to medical therapy among Profile 4 and 5 patients (p = 0.0092). Baseline health-related quality of life was lower among patients receiving a LVAD than those enrolled on continuing oral medical therapy, but increased after 1 year for survivors in both cohorts. CONCLUSIONS: Ambulatory patients with advanced HF are at high risk for poor outcomes, with only 53% alive on medical therapy after 2 years of follow-up. Survival was similar for medical and LVAD therapy in the overall cohort, which included the lower severity Profiles 6 and 7, but survival was better with LVAD therapy among patients in Profiles 4 and 5. Given the poor outcomes in this group of advanced HF patients, timely consideration of transplant and LVAD is of critical importance. (C) 2018 International Society for Heart and Lung Transplantation. All rights reserved.

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