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Timing of a BiVAD: Does Earlier RVAD Implant Confer a Survival Advantage?
Shannon Oliver
1, Matthew O'Connor
2, Steve Kindel
3, John Dykes
4, Sabrina Law
5, Lindsay May
8, Aamir Jeewa
6, Matthew Zinn
7, Ryan Butts
9, Bethany Wisotzkey
10, Muhammad Shezad
11, Jennifer Conway
1
1Stollery Children's Hospital, Edmonton , AB, Canada. 2Children's Hospital of Philadelphia, Philadelphia, PA, United States 3Children's Wisconsin, Milwaukee, WI, United States 4Stanford, Stanford, CA, United States 5Columbia, New York, NY, United States 6The Hospital for Sick Children, Toronto, ON, Canada. 7Children's Hospital of Pittsburgh, Pittsburgh, PA, United States 8University of Utah, Salt Lake City, UT, United States 9UT Southwestern, Dallas, TX, United States 10Seattle Children's Hospital, Seattle, WA, United States 11Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
Background: Patients requiring a biventricular assist device (BiVAD) are reported to have worse survival outcomes then those who require left ventricular assist devices (LVAD) alone. However, it is not clear whether this survival difference is related to the need for BiVAD per se versus the timing of BiVAD implantation.
Methods: Prospectively collected data for patients who underwent BiVAD implant between 04/2018 and 12/2022 was obtained from the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) database. Patients were dichotomized into primary (RVAD at time of LVAD) and delayed (RVAD implanted after LVAD) BiVAD implant. Temporary RVADs implanted at time of LVAD were considered as a primary BiVAD. Patients were excluded from the final analysis if their RVAD was implanted ?60-days after their LVAD. Pre-implant demographic and clinical characteristics were collected and compared between the two groups. Kaplan-Meier analysis was used to determine survival differences.
Results: BiVAD implantation was performed in 243 patients, with 20 patients excluded as they had their RVAD placed beyond 60 days after the initial LVAD. Of the 223 patients who underwent BiVAD implant, 186 (83.4%) had primary BiVAD and 37 (16.6%) had delayed BiVAD implant. This accounts for 12.6% (223/1761) of all ventricular assist devices (VADs) implanted in the ACTION database. There was no difference between primary and delayed BiVAD implant with regards to sex distribution (47.8% vs 35.1% female, p=0.156), median age [5.58 years (IQR 0.92, 11.56) vs 3.46 years (IQR 1.17, 14.9), p=0.290] or proportion of patients with congenital heart disease (CHD) (24.7% vs 16.2% p=0.271). There was no significant difference between the baseline clinical status of the two groups except for a higher proportion being dialysis dependent (11.8% vs 0% p=0.028) and having had previous sternotomies (39.2% vs 27%, p=0.004) in the primary BiVAD group. Post BiVAD implant, there were no difference between duration of intensive care admission [44 days (IQR 18.2, 81.2) vs 37.5 days (IQR 21, 76.7), p=0.982] or duration of time on the device before transplant/recovery [72 days (IQR 30.7, 151.6) vs 66 days (IQR 30.2, 179), p=0.716]. Patients who were a primary BiVAD implant had a significantly better 1-year survival then patients who were delayed BiVAD implant (Figure).
Conclusions: In patients who undergo primary BiVAD implantation, there is significantly lower mortality rates than in patients with a delayed BiVAD. This suggests that the timing of implantation drives outcomes rather than the need for BiVAD support. Clinical teams should consider early implantation of an RVAD in patients with concerns of right heart failure.
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