Impact of Ventricular Assist Device Implantation on Clinical and Economic Outcomes of Heart Transplantation in the United States from 2003-2007

Julie W. Doberne, Brian Diggs, Frederick Tibayan, Matthew Slater, Christopher V. Chien, Jill Gelow, James Mudd, Howard K. Song

Divisions of Cardiothoracic Surgery and Cardiovascular Medicine, Oregon Health & Science University, Portland, USA.

DOI: 10.4236/wjcs.2013.35032                

Abstract

The use of ventricular assist devices (VADs) as a bridge to transplantation (BTT) has evolved considerably as clinical experience has grown and newer generation devices have become available. This study investigated the impact of VAD implantation on the clinical and economic outcomes of patients undergoing heart transplantation in the United States(US) from 2003-2007. A retrospective study was carried out using the Nationwide Inpatient Sample, to track the characteristics and outcomes of an estimated 7859 patients undergoing heart transplantation in the United States from 2003-2007. Patients were divided based on whether they were bridged to transplant with a VAD and whether they were outpatient (VAD Outpt) or inpatient (VAD Inpt). Multivariate analysis was performed to identify risk factors for inhospital mortality following heart transplantation. Hospital costs were also measured. A VAD was used as a BTT in 20.8% of patients undergoing heart transplantation during the study period. Early in the series the frequency of VAD Outpts and Inpts was similar but in later years patients were more commonly bridged as outpatients. Hospital mortality for the entire population was 6.2%. Multivariate analysis identified several risk factors for mortality, including advanced age, history of congenital heart disease, and VAD Inpt status. VAD Inpt status was the strongest predictor of mortality. The hospital cost of patients bridged as inpatients was more than double the cost of outpatients. Median hospital cost declined by 11% over the study period, from $115,868 to $103,578. Much of this cost reduction was related to the shift in VAD status from Inpt to Outpt. Heart transplant recipients are increasingly bridged to transplantation with VADs as outpatients. Those bridged as inpatients have substantially higher hospital mortality and cost. These findings have important clinical implications and should inform policy development, resource utilization and donor allocation.

Keywords

Ventricular Assist Device; Heart Transplantation; Cost Effectiveness

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	L. W. Miller, F. D. Pagani, S. D. Russell, R. John, A. J. Boyle, K. D. Aaronson, et al., “Use of a Continuous-Flow Device in Patients Awaiting Heart Transplantation,” The New England Journal of Medicine, Vol. 357, No. 9, 2007, pp. 885-896. doi:10.1056/NEJMoa067758
[2]	D. Esmore, D. Kaye, P. Spratt, R. Larbalestier, P. Ruygrok, S. Tsui, et al., “A Prospective, Multicenter Trial of the Ventrassist Left Ventricular Assist Device for Bridge to Transplant: Safety and Efficacy,” The Journal of Heart and Lung Transplantation, Vol. 27, No. 6, 2008, pp. 579-588. doi:10.1016/j.healun.2008.02.012
[3]	M. C. Deng, L. B. Edwards, M. I. Hertz, A. W. Rowe, B. M. Keck, R. Kormos, et al., “Mechanical Circulatory Support Device Database of the International Society for Heart and Lung Transplantation: Third Annual Report— 2005,” The Journal of Heart and Lung Transplantation, Vol. 24, No. 9, 2005, pp. 1182-1187. doi:10.1016/j.healun.2005.07.002
[4]	O. H. Frazier, E. A. Rose, M. C. Oz, W. Dembitsky, P. McCarthy, B. Radovancevic, et al., “Multicenter Clinical Evaluation of the Heartmate Vented Electric Left Ventricular Assist System in Patients Awaiting Heart Transplantation,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 122, No. 6, 2001, pp. 1186-1195. doi:10.1067/mtc.2001.118274
[5]	J. K. Kirklin, D. C. Naftel, L. W. Stevenson, R. L. Kormos, F. D. Pagani, M. A. Miller, et al., “INTERMACS Database for Durable Devices for Circulatory Support: First Annual Report,” The Journal of Heart and Lung Transplantation, Vol. 27, No.10, 2008, pp. 1065-1072. doi:10.1016/j.healun.2008.07.021
[6]	L. W. Miller, K. E. Nelson, R. R. Bostic, K. Tong, M. S. Slaughter and J. W. Long, “Hospital Costs for Left Ventricular Assist Devices for Destination Therapy: Lower Costs for Implantation in the Post-REMATCH Era,” The Journal of Heart and Lung Transplantation, Vol. 25, No. 7, 2006, pp. 778-784. doi:10.1016/j.healun.2006.03.010
[7]	S. E. Sandner, D. Zimpfer, P. Zrunek, A. Rajek, H. Schima, D. Dunkler, et al., “Age and Outcome after Continuous-Flow Left Ventricular Assist Device Implantation as Bridge to Transplantation,” The Journal of Heart and Lung Transplantation, Vol. 28, No. 4, 2009, pp. 367-372. doi:10.1016/j.healun.2009.01.008
[8]	M. C. Deng, M. Loebe, A. El-Banayosy, E. Gronda, P. G. Jansen, M. Vigano, et al., “Mechanical Circulatory Support for Advanced Heart Failure: Effect of Patient Selection on Outcome,” Circulation, Vol. 103, No. 2, 2001, pp. 231-237. doi:10.1161/01.CIR.103.2.231
[9]	V. Patlolla, R. D. Patten, D. Denofrio, M. A. Konstam and R. Krishnamani, “The Effect of Ventricular Assist Devices on Post-Transplant Mortality an Analysis of the United Network for Organ Sharing Thoracic Registry,” Journal of the American College of Cardiology, Vol. 53, No. 3, 2009, pp. 264-271. doi:10.1016/j.jacc.2008.08.070
[10]	J. S. Gammie, L. B. Edwards, B. P. Griffith, R. N. Griffith and L. Tsao, “Optimal Timing of Cardiac Transplantation after Ventricular Assist Device Implantation,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 127, No. 6, 2004, pp. 1789-1799. doi:10.1016/j.jtcvs.2003.12.018
[11]	R. John, F. D. Pagani, Y. Naka, A. Boyle, J. V. Conte, S. D. Russell, et al., “Post-Cardiac Transplant Survival after Support with a Continuous-Flow Left Ventricular Assist Device: Impact of Duration of Left Ventricular Assist Device Support and Other Variables,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 140, No. 1, 2010, pp. 174-181. doi:10.1016/j.jtcvs.2010.03.037
[12]	“Introduction to the HCUP Nationwide Inpatient Sample (NIS) 2007,” Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, US Department of Health and Human Services, 2009.
[13]	“2009 Annual Report of the US Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients: Transplant Data 1997-2008,” Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau, Division of Transplantation, Rockville, United Network for Organ Sharing, Richmond, University Renal Research and Education Association, Ann Arbor.
[14]	S. M. Martinelli, U. D. Patel, B. G. Phillips-Bute, C. A. Milano, L. E. Archer, M. Stafford-Smith, et al., “Trends in Cardiac Surgery-Associated Acute Renal Failure in the United States: A Disproportionate Increase after Heart Transplantation,” Renal Failure, Vol. 31, No. 8, 2009, pp. 633-640. doi:10.3109/08860220903100689
[15]	D. Chu, F. G. Bakaeen, T. K. Dao, S. A. LeMaire, J. S. Coselli and J. Huh, “On-Pump versus Off-Pump Coronary Artery Bypass Grafting in a Cohort of 63,000 Patients,” The Annals of Thoracic Surgery, Vol. 87, No. 6, 2009, pp. 1820-1826. doi:10.1016/j.athoracsur.2009.03.052
[16]	H. Luckraz, M. Goddard, S. C. Charman, J. Wallwork, J. Parameshwar and S. R. Large, “Early Mortality after Cardiac Transplantation: Should We Do Better?” The Journal of Heart and Lung Transplantation, Vol. 24, No. 4, 2005, pp. 401-405. doi:10.1016/j.healun.2004.02.013
[17]	P. Demers, S. Moffatt, P. E. Oyer, S. A. Hunt, B. A. Reitz and R. C. Robbins, “Long-Term Results of Heart Transplantation in Patients Older than 60 Years,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 126, No. 1, 2003, pp. 224-231. doi:10.1016/S0022-5223(03)00055-2
[18]	V. K. Topkara, N. C. Dang, T. P. Martens, F. H. Cheema, J. F. Liu, M. Argenziano, et al., “Bridging to Transplantation with Left Ventricular Assist Devices: Outcomes in Patients Aged 60 Years and Older,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 130, No. 3, 2005, pp. 881-882. doi:10.1016/j.jtcvs.2005.03.009
[19]	P. L. Digiorgi, M. S. Reel, B. Thornton, E. Burton, Y. Naka and M. C. Oz, “Heart Transplant and Left Ventricular Assist Device Costs,” The Journal of Heart and Lung Transplantation, Vol. 24, No. 2, 2005, pp. 200-204. doi:10.1016/j.healun.2003.11.397
[20]	A. F. Hernandez, A. M. Shea, C. A. Milano, J. G. Rogers, B. G. Hammill, C. M. O’Connor, et al., “Long-Term Outcomes and Costs of Ventricular Assist Devices among Medicare Beneficiaries,” JAMA: The Journal of the American Medical Association, Vol. 300, No. 20, 2008, pp. 2398-2406. doi:10.1001/jama.2008.716
[21]	A. J. Moskowitz, E. A. Rose and A. C. Gelijns, “The Cost of Long-Term LVAD Implantation,” The Annals of Thoracic Surgery, Vol. 71, Supplement 3, 2001, pp. S195-S198. doi:10.1016/S0003-4975(00)02621-7
[22]	S. Osaki, N. M. Edwards, M. R. Johnson, M. Velez, A. Munoz, L. Lozonschi, et al., “Improved Survival after Heart Transplantation in Patients with Bridge to Transplant in the Recent Era: A 17-Year Single-Center Experience,” The Journal of Heart and Lung Transplantation, Vol. 28, No. 6, 2009, pp. 591-597. doi:10.1016/j.healun.2009.03.008
[23]	J. A. Morgan, R. John, V. Rao, A. D. Weinberg, B. J. Lee, P. A. Mazzeo, et al., “Bridging to Transplant with the HeartMate Left Ventricular Assist Device: The Columbia Presbyterian 12-Year Experience,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 127, No. 5, 2004, pp. 1309-1316. doi:10.1016/j.jtcvs.2003.07.035
[24]	J. MacIver, H. J. Ross, D. H. Delgado, R. J. Cusimano, T. M. Yau, M. Rodger, et al., “Community Support of Patients with a Left Ventricular Assist Device: The Toronto General Hospital Experience,” The Canadian Journal of Cardiology, Vol. 25, No. 11, 2009, pp. e377-e381. doi:10.1016/S0828-282X(09)70164-3
[25]	D. L. Morales, K. A. Catanese, D. N. Helman, M. R. Williams, A. Weinberg, D. J. Goldstein, et al., “Six-Year Experience of Caring for Forty-Four Patients with a Left Ventricular Assist Device at Home: Safe, Economical, Necessary,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 119, No. 2, 2000, pp. 251-259. doi:10.1016/S0022-5223(00)70180-2