Is mechanically bridging patients with a failing cardiac graft to retransplantation an effective therapy? Analysis of the United Network of Organ Sharing database.

BACKGROUND: The results of bridging patients with cardiac allograft failure to retransplantation (ReTx) with mechanical circulatory support (MCS) have not been well studied. The United Network of Organ Sharing (UNOS) database was used to analyze outcomes of patients successfully bridged with MCS to cardiac ReTx.

METHODS: Of 1,690 cardiac ReTx identified in the UNOS database from October 1987 to July 2011, 149 (8.8%) were bridged to ReTx with MCS.

RESULTS: Patients bridged to ReTx with MCS had a poorer survival than patients not bridged (p < 0.0001). ReTx after ventricular assist device (VAD) support had better survival than ReTx after extracorporeal membrane oxygenation (ECMO; half-life, 3.9 years vs 61 days, p = 0.026). For patients bridged to ReTx, graft survival was 40% for ReTx within 1 year of primary Tx vs 64% (p = 0.003). When ReTx was performed 1 year after cardiac Tx, survival was similar in patients bridged with a VAD and those not bridged (mean, 7.5 vs 8.7 years; p = 0.8). Survival for patients bridged to ReTx with ECMO was consistently worse (p ≤ 0.05) in all analyses. The 1-year survival of ReTx after VAD performed in 2003 to 2011 (67%) was better than in the earlier era of 1987 to 2002 (37%, p = 0.005).

CONCLUSIONS: Bridging patients to ReTx with ECMO at any time is not advisable. Bridging patients with MCS to ReTx within 1 year of primary cardiac Tx is not advisable. Survival after ReTx for patients bridged by VAD has improved considerably over time. Patients who survive the first year after cardiac Tx can be bridged by VAD to ReTx with an expectation that outcomes can be similar to ReTx patients who did not require MCS.