Outcomes of Patients Implanted With a Left Ventricular Assist Device at Nontransplant Mechanical Circulatory Support Centers

Abstract

The goal of this study was to assess outcomes of patients who underwent implantation of left ventricular assist devices (LVADs) at nontransplantation mechanical circulatory support centers. As the availability of LVADs for advanced heart failure has expanded to nontransplantation mechanical circulatory support centers, concerns have been expressed about maintaining good outcomes. Demographics and outcomes were evaluated in 276 patients with advanced heart failure who underwent implantation of LVADs as bridge to transplantation or destination therapy at 27 open-heart centers. Baseline characteristics, operative mortality, length of stay, readmission rate, adverse events, quality of life, and survival were analyzed. The overall 30-day mortality was 3% (8 of 276), and survival rates at 6, 12, and 24 months, respectively, were 92 ± 2%, 88 ± 3%, and 84 ± 4% for the bridge-to-transplantation group and 81 ± 3%, 70 ± 5%, and 63 ± 6% for the destination therapy group, comparable with results published by the national Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). The median length of stay for all patients was 21 days. Bleeding was the most frequent adverse event. Stroke occurred in 4% (bridge to transplantation) and 6% (destination therapy) of patients. Quality-of-life measures and 6-minute walk distances showed sustained improvements throughout support. In conclusion, outcomes with LVAD support at open-heart centers are acceptable and comparable with results from the INTERMACS registry. With appropriate teams, training, center commitment, and certification, LVAD therapy is being disseminated in a responsible way to open-heart centers. The goal of this study was to assess outcomes of patients who underwent implantation of left ventricular assist devices (LVADs) at nontransplantation mechanical circulatory support centers. As the availability of LVADs for advanced heart failure has expanded to nontransplantation mechanical circulatory support centers, concerns have been expressed about maintaining good outcomes. Demographics and outcomes were evaluated in 276 patients with advanced heart failure who underwent implantation of LVADs as bridge to transplantation or destination therapy at 27 open-heart centers. Baseline characteristics, operative mortality, length of stay, readmission rate, adverse events, quality of life, and survival were analyzed. The overall 30-day mortality was 3% (8 of 276), and survival rates at 6, 12, and 24 months, respectively, were 92 ± 2%, 88 ± 3%, and 84 ± 4% for the bridge-to-transplantation group and 81 ± 3%, 70 ± 5%, and 63 ± 6% for the destination therapy group, comparable with results published by the national Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). The median length of stay for all patients was 21 days. Bleeding was the most frequent adverse event. Stroke occurred in 4% (bridge to transplantation) and 6% (destination therapy) of patients. Quality-of-life measures and 6-minute walk distances showed sustained improvements throughout support. In conclusion, outcomes with LVAD support at open-heart centers are acceptable and comparable with results from the INTERMACS registry. With appropriate teams, training, center commitment, and certification, LVAD therapy is being disseminated in a responsible way to open-heart centers. Treatment of advanced-stage heart failure with left ventricular assist device (LVAD) support provides quality-of-life and survival benefit in most recipients.1Miller L.W. Pagani F.D. Russell S.D. Ranjit J. Boyle A.J. Aaronson K.D. Conte J.V. Naka Y. Mancini D. Delgado R.M. MacGillivray T.E. Farrar D.J. Frazier O.H. for the HeartMate II Clinical InvestigatorsUse of a continuous-flow device in patients awaiting heart transplantation.N Engl J Med. 2007; 357: 885-896Crossref PubMed Scopus (1442) Google Scholar, 2Pagani F.D. Miller L.W. Russell S.D. Aaronson K.D. John R. Boyle A.J. Conte J.V. Bogaev R.C. MacGillivray T.E. Naka Y. Mancini D. Massey H.T. Chen L. Klodell C.T. Aranda J.M. Moazami N. Ewald G.A. Farrar D.J. Frazier O.H. HeartMate II InvestigatorsExtended mechanical circulatory support with a continuous-flow rotary left ventricular assist device.J Am Coll Cardiol. 2009; 54: 312-321Abstract Full Text Full Text PDF PubMed Scopus (736) Google Scholar, 3Slaughter M.S. Rogers J.G. Milano C.A. Russell S.D. Conte J.V. Feldman D. Sun B. Tatooles A.J. Delgado 3rd, R.M. Long J.W. Wozniak T.C. Ghumman W. Farrar D.J. Frazier O.H. HeartMate II Investigators. Advanced heart failure treated with continuous-flow left ventricular assist device.N Engl J Med. 2009; 361: 2241-2251Crossref PubMed Scopus (2480) Google Scholar, 4John R. Naka Y. Smedira N.G. Starling R. Jorde U. Eckman P. Farrar D.J. Pagani F.D. Continuous flow left ventricular assist device outcomes in commercial use compared with the prior clinical trial.Ann Thorac Surg. 2011; 92 (discussion 1413): 1406-1413Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 5Starling R.C. Naka Y. Boyle A.J. Gonzalez-Stawinski G. John R. Jorde U. Russell S.D. Conte J.V. Aaronson K.D. McGee Jr., E.C. Cotts W.G. DeNofrio D. Pham D.T. Farrar D.J. Pagani F.D. Results of the post-U.S. Food and Drug Administration-approval study with a continuous-flow left ventricular assist device as a bridge to heart transplantation: a prospective study using the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support).J Am Coll Cardiol. 2011; 57: 1890-1898Abstract Full Text Full Text PDF PubMed Scopus (377) Google Scholar, 6Park S.J. Milano C.A. Tatooles A.J. Rogers J.G. Adamson R.M. Steidley D.E. Ewald G.A. Sundareswaran K.S. Farrar D.J. Slaughter M.S. HeartMate II Clinical InvestigatorsOutcomes in advanced heart failure patients with left ventricular assist devices for destination therapy.Circ Heart Fail. 2012; 5: 241-248Crossref PubMed Scopus (278) Google Scholar The development of LVAD technology has been closely associated with heart transplantation, while the greatest potential for expanded use is for destination therapy (DT) in nontransplantation candidates.7Kirklin J.K. Naftel D.C. Pagani F.D. Kormos R.L. Stevenson L. Miller M. Young J. Long-term mechanical circulatory support (destination therapy): on track to compete with heart transplantation?.J Thorac Cardiovasc Surg. 2012; 144 (discussion 597–598.): 584-603Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar, 8Starling R.C. Gorodeski E.Z. Potential population for long-term use of left ventricular assist devices.in: Kormos R.L. Miller L.W. Mechanical Circulatory Support: A Companion to Braunwald's Heart Disease. Elsevier, Philadelphia, PA2012: 11-20Crossref Google Scholar The use of LVADs beyond heart transplantation centers has been somewhat controversial because of concerns about adequate training, clinical experience, and the availability of necessary resources.9Stewart G.C. Givertz M.M. Mechanical circulatory support for advanced heart failure: patients and technology in evolution.Circulation. 2012; 125: 1304-1315Crossref PubMed Scopus (153) Google Scholar, 10Stewart G.C. Stevenson L.W. Keeping left ventricular assist device acceleration on track.Circulation. 2011; 123 (discussion 1568): 1559-1568Crossref PubMed Scopus (50) Google Scholar In 2009, after commercial approval of the HeartMate II LVAD (Thoratec Corporation, Pleasanton, California) for bridge to transplantation (BTT), nontransplantation mechanical circulatory support (MCS) centers began implanting this device with the support of partnering MCS-transplantation centers. Today, LVAD implantation for BTT and DT is performed regularly at MCS centers. This report provides outcome data for patients who underwent LVAD implantation as BTT and DT at nontransplantation MCS centers. This retrospective study was conducted using data from 276 patients who underwent implantation of the HeartMate II LVAD at 27 MCS centers as BTT and DT. Patient data are presented by indication, BTT (n = 100) or DT (n = 176), as identified by the implanting center. Implantation of the HeartMate II LVAD at the MCS centers began in April 2009, after commercial approval of the device as BTT. Before starting LVAD implantation at the MCS centers, agreements were established with partnering MCS-transplantation centers to ensure that heart transplantation candidates were evaluated and listed according to the guidelines of the United Network for Organ Sharing. The partnering MCS-transplantation centers provided workup and care protocols specific to their programs and served as resources for information on case management as needed. All patients were enrolled in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) and gave informed consent that was approved by the institutional review board at each of the participating centers. The time frame for the data used in this study extends from the date of the first HeartMate II implantation as BTT at an MCS center (April 2009) to September 30, 2012. The first implantation for the DT indication occurred in January 2012. Each participating center entered data into the registry according to instructions in the INTERMACS manual of operations. Data obtained from INTERMACS for this study were the subset of patients who underwent implantation at the MCS centers. Baseline characteristics, operative mortality, major adverse event rates, length of stay in the hospital, rehospitalization rate, physical status, quality-of-life measures, and survival to 2 years were analyzed. Data for 30-day, 6-month, and 12-month survival that were grouped by INTERMACS profiles (profiles 1, 2, 3, and 4 to 7) were assessed for differences based on severity of illness. Reported adverse events are defined by the INTERMACS protocol. Physical status evaluated with the 6-minute walk test and quality-of-life measures evaluated with the EuroQol EQ-5D visual analog scale and total quality-of-life scores at baseline, 3, 6, and 12 months were analyzed. The total quality-of-life score is a composite score evaluating anxieties, mobility, pain, and self-care. Continuous data are reported as mean ± SD, and discrete variables are reported as percentages. Survival analysis was performed using the Kaplan-Meier method with censoring when LVAD support was stopped for heart transplantation or when recovery enabled device removal. Adverse events are given as the total number of events and the event rate (number of events divided by total patient-years). Statistical analyses were performed using SAS version 9.2 (SAS Institute Inc., Cary, North Carolina). Data are presented in 2 groups according to indication for LVAD support (BTT or DT), but statistical comparisons between the groups were not performed. The baseline characteristics for patients who underwent implantation of the HeartMate II as BTT (n = 100), as DT (n = 176), and the 2 groups combined (n = 276) are listed in Table 1. The 2 groups were composed predominantly of men, and the age distribution (ranges defined by INTERMACS) was consistent with the indication for support (i.e., 35% of patients were >70 years of age in the DT group, and only 6% were >70 years of age in the BTT group). Most BTT patients (67%) were 50 to 69 years of age, and those in the DT group were predominately >60 years of age (72%). The severity of illness defined on the basis of INTERMACS profile was similar for the 2 groups. Patients with critical cardiogenic shock (INTERMACS profile 1) represented the smallest proportion in both groups. Hemodynamic and laboratory parameters for the 2 groups were representative of advanced-stage heart failure.Table 1Baseline characteristicsVariableBridge-to-Transplant (n = 100)Destination Therapy (n = 176)All (N = 276)Males81 (81%)145 (82%)226 (82%)Age (Years)≤5962 (62%)49 (28%)111 (40%)60–6932 (32%)65 (37%)97 (35%)≥706 (6%)62 (35%)68 (25%)Heart Failure EtiologyIschemic cardiomyopathy43 (43%)103 (59%)146 (53%)Idiopathic cardiomyopathy34 (34%)48 (27%)82 (30%)Other etiology24 (24%)25 (14%)49 (18%)INTERMACS Profile1: Critical cardiogenic shock7 (7%)17 (10%)24 (9%)2: Progressive decline32 (32%)52 (30%)84 (30%)3: Stable but inotrope dependent44 (44%)72 (41%)116 (42%)4–7: Non-inotrope dependent17 (17%)35 (20%)52 (19%)HemodynamicsHeart rate (bpm)85.8 ±17.784.9 ±15.085.2 ±16.1Mean blood pressure (mmHg)78.7 ±10.676.7 ±11.177.4 ±11.0Pulmonary wedge pressure (mmHg)22.9 ±10.422.9 ±8.122.9 ±9.0Right atrial pressure (mmHg)13.2 ±8.413.8 ±7.713.6 ±7.9Cardiac index (L/min/m2)2.14 ±0.632.12 ±0.672.12 ±0.65Laboratory DataBlood urea nitrogen (mg/L)23.8 ±13.429.4 ±15.027.4 ±14.6Creatinine (mg/dL)1.25 ±0.471.46 ±0.721.39 ±0.65Total bilirubin (mg/dL)1.34 ±1.141.40 ±1.611.38 ±1.46Serum glutamic oxaloacetic transaminase (u/L)39.6 ±30.549.0 ±96.345.6 ±79.0Serum glutamic pyruvic transaminase (u/L)45.8 ±49.850.5 ±87.348.8 ±75.7International normalized ratio1.36 ±0.461.29 ±0.231.31 ±0.33 Open table in a new tab The average duration of support for all MCS center patients (n = 276) was 8.3 ± months to and was ± months for BTT and ± months for DT of DT patients occurred because centers only DT The duration was for BTT and for DT. the time of the analysis date of the BTT patients and of the DT patients heart support occurred in of BTT patients and in of DT patients The number of patients on LVAD support was of 276 of BTT patients and of DT patients (72%). the device after 4 patients underwent device because of and 2 devices were for device The overall 30-day mortality was 3% (8 of 276), with 2 in the BTT group that were INTERMACS profile 2 and profile 3, respectively, and in the DT group that were INTERMACS profile (n = or profile 2 (n = The survival rates by INTERMACS profile are given in Table The Kaplan-Meier survival rates 1) at 6, 12, and 24 months, respectively, for the BTT group were 92 ± 2%, 88 ± 3%, and 84 ± for the DT group, the survival rates were 81 ± 3%, 70 ± 5%, and 63 ± rate and number of patients by INTERMACS to = = = = were for and or support was for 12 = not Open table in a new tab Patients were for and or support was for 12 = not The 276 patients underwent implantation of the HeartMate II at 27 MCS centers with an average of ± to center The survival rates at 1, 6, and 12 months at the centers with (n = were ± ± and ± respectively, and at centers with the rates were ± ± and ± = number of for bridge to destination therapy and total number of by MCS to Heart Heart of of Open table in a new tab LVAD the median length of stay in the was 21 for all MCS center and was for DT patients for BTT patients The of patients after LVAD implantation were for BTT for DT and for all patients. The readmission rate was events for for The for readmission in the DT are listed in Table for readmission for the destination therapy of device not Open table in a new tab The most adverse event was and is presented as of or was by device and The overall adverse event rates were for the DT rates for the bridge to and destination therapy Bleeding Open table in a new tab BTT and DT patients quality of at the time with the improvements to 12 months months after the mean on the visual analog scale by for the BTT group and for the DT group In the time the total mean composite quality-of-life score quality of by for BTT patients and for DT patients was in 6-minute walk distances from to months, with walk distances by the 2 groups of patients 12 months The number of patients participating in quality-of-life because of severity of or to the and given the by centers. In has been to the outcomes of patients who LVAD support as BTT and DT. The survival rate for the BTT indication has from in the of the clinical L.W. Pagani F.D. Russell S.D. Ranjit J. Boyle A.J. Aaronson K.D. Conte J.V. Naka Y. Mancini D. Delgado R.M. MacGillivray T.E. Farrar D.J. Frazier O.H. for the HeartMate II Clinical InvestigatorsUse of a continuous-flow device in patients awaiting heart transplantation.N Engl J Med. 2007; 357: 885-896Crossref PubMed Scopus (1442) Google Scholar to in R. Naka Y. Smedira N.G. Starling R. Jorde U. Eckman P. Farrar D.J. Pagani F.D. Continuous flow left ventricular assist device outcomes in commercial use compared with the prior clinical trial.Ann Thorac Surg. 2011; 92 (discussion 1413): 1406-1413Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 5Starling R.C. Naka Y. Boyle A.J. Gonzalez-Stawinski G. John R. Jorde U. Russell S.D. Conte J.V. Aaronson K.D. McGee Jr., E.C. Cotts W.G. DeNofrio D. Pham D.T. Farrar D.J. Pagani F.D. Results of the post-U.S. Food and Drug Administration-approval study with a continuous-flow left ventricular assist device as a bridge to heart transplantation: a prospective study using the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support).J Am Coll Cardiol. 2011; 57: 1890-1898Abstract Full Text Full Text PDF PubMed Scopus (377) Google Scholar for patients for the DT indication, survival has from in the clinical M.S. Rogers J.G. Milano C.A. Russell S.D. Conte J.V. Feldman D. Sun B. Tatooles A.J. Delgado 3rd, R.M. Long J.W. Wozniak T.C. Ghumman W. Farrar D.J. Frazier O.H. HeartMate II Investigators. Advanced heart failure treated with continuous-flow left ventricular assist device.N Engl J Med. 2009; 361: 2241-2251Crossref PubMed Scopus (2480) Google Scholar to in the INTERMACS J.K. Naftel D.C. Pagani F.D. Kormos R.L. Stevenson L.W. Miller J. Young INTERMACS a Heart Full Text Full Text PDF PubMed Scopus Google Scholar In this study at MCS centers, the and survival rates, respectively, were and for BTT patients and and for DT patients results are comparable with those from the INTERMACS registry as a and that good outcomes in patients who LVAD implantation at MCS from heart centers in the study compared to outcomes from the HeartMate II clinical and INTERMACS of study Heart Clinical L.W. Pagani F.D. Russell S.D. Ranjit J. Boyle A.J. Aaronson K.D. Conte J.V. Naka Y. Mancini D. Delgado R.M. MacGillivray T.E. Farrar D.J. Frazier O.H. for the HeartMate II Clinical InvestigatorsUse of a continuous-flow device in patients awaiting heart transplantation.N Engl J Med. 2007; 357: 885-896Crossref PubMed Scopus (1442) Google Clinical F.D. Miller L.W. Russell S.D. Aaronson K.D. John R. Boyle A.J. Conte J.V. Bogaev R.C. MacGillivray T.E. Naka Y. Mancini D. Massey H.T. Chen L. Klodell C.T. Aranda J.M. Moazami N. Ewald G.A. Farrar D.J. Frazier O.H. HeartMate II InvestigatorsExtended mechanical circulatory support with a continuous-flow rotary left ventricular assist device.J Am Coll Cardiol. 2009; 54: 312-321Abstract Full Text Full Text PDF PubMed Scopus (736) Google R.C. Naka Y. Boyle A.J. Gonzalez-Stawinski G. John R. Jorde U. Russell S.D. Conte J.V. Aaronson K.D. McGee Jr., E.C. Cotts W.G. DeNofrio D. Pham D.T. Farrar D.J. Pagani F.D. Results of the post-U.S. Food and Drug Administration-approval study with a continuous-flow left ventricular assist device as a bridge to heart transplantation: a prospective study using the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support).J Am Coll Cardiol. 2011; 57: 1890-1898Abstract Full Text Full Text PDF PubMed Scopus (377) Google R. Naka Y. Smedira N.G. Starling R. Jorde U. Eckman P. Farrar D.J. Pagani F.D. Continuous flow left ventricular assist device outcomes in commercial use compared with the prior clinical trial.Ann Thorac Surg. 2011; 92 (discussion 1413): 1406-1413Abstract Full Text Full Text PDF PubMed Scopus (89) Google Registry J.K. Naftel D.C. Pagani F.D. Kormos R.L. Stevenson L.W. Miller J. Young INTERMACS a Heart Full Text Full Text PDF PubMed Scopus Google Therapy Heart Clinical 2009) 3Slaughter M.S. Rogers J.G. Milano C.A. Russell S.D. Conte J.V. Feldman D. Sun B. Tatooles A.J. Delgado 3rd, R.M. Long J.W. Wozniak T.C. Ghumman W. Farrar D.J. Frazier O.H. HeartMate II Investigators. Advanced heart failure treated with continuous-flow left ventricular assist device.N Engl J Med. 2009; 361: 2241-2251Crossref PubMed Scopus (2480) Google Clinical 6Park S.J. Milano C.A. Tatooles A.J. Rogers J.G. Adamson R.M. Steidley D.E. Ewald G.A. Sundareswaran K.S. Farrar D.J. Slaughter M.S. HeartMate II Clinical InvestigatorsOutcomes in advanced heart failure patients with left ventricular assist devices for destination therapy.Circ Heart Fail. 2012; 5: 241-248Crossref PubMed Scopus (278) Google Registry J.K. Naftel D.C. Pagani F.D. Kormos R.L. Stevenson L.W. Miller J. Young INTERMACS a Heart Full Text Full Text PDF PubMed Scopus Google Open table in a new tab The results of this study that patients with advanced-stage heart failure who implantation of LVADs have quality of and for in to the improvements in the quality-of-life measures, physical was as by the in the 6-minute walk Adverse event rates to acceptable as are not from of the clinical L.W. Pagani F.D. Russell S.D. Ranjit J. Boyle A.J. Aaronson K.D. Conte J.V. Naka Y. Mancini D. Delgado R.M. MacGillivray T.E. Farrar D.J. Frazier O.H. for the HeartMate II Clinical InvestigatorsUse of a continuous-flow device in patients awaiting heart transplantation.N Engl J Med. 2007; 357: 885-896Crossref PubMed Scopus (1442) Google Scholar, 2Pagani F.D. Miller L.W. Russell S.D. Aaronson K.D. John R. Boyle A.J. Conte J.V. Bogaev R.C. MacGillivray T.E. Naka Y. Mancini D. Massey H.T. Chen L. Klodell C.T. Aranda J.M. Moazami N. Ewald G.A. Farrar D.J. Frazier O.H. HeartMate II InvestigatorsExtended mechanical circulatory support with a continuous-flow rotary left ventricular assist device.J Am Coll Cardiol. 2009; 54: 312-321Abstract Full Text Full Text PDF PubMed Scopus (736) Google Scholar, 3Slaughter M.S. Rogers J.G. Milano C.A. Russell S.D. Conte J.V. Feldman D. Sun B. Tatooles A.J. Delgado 3rd, R.M. Long J.W. Wozniak T.C. Ghumman W. Farrar D.J. Frazier O.H. HeartMate II Investigators. Advanced heart failure treated with continuous-flow left ventricular assist device.N Engl J Med. 2009; 361: 2241-2251Crossref PubMed Scopus (2480) Google Scholar, 4John R. Naka Y. Smedira N.G. Starling R. Jorde U. Eckman P. Farrar D.J. Pagani F.D. Continuous flow left ventricular assist device outcomes in commercial use compared with the prior clinical trial.Ann Thorac Surg. 2011; 92 (discussion 1413): 1406-1413Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 5Starling R.C. Naka Y. Boyle A.J. Gonzalez-Stawinski G. John R. Jorde U. Russell S.D. Conte J.V. Aaronson K.D. McGee Jr., E.C. Cotts W.G. DeNofrio D. Pham D.T. Farrar D.J. Pagani F.D. Results of the post-U.S. Food and Drug Administration-approval study with a continuous-flow left ventricular assist device as a bridge to heart transplantation: a prospective study using the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support).J Am Coll Cardiol. 2011; 57: 1890-1898Abstract Full Text Full Text PDF PubMed Scopus (377) Google Scholar, 6Park S.J. Milano C.A. Tatooles A.J. Rogers J.G. Adamson R.M. Steidley D.E. Ewald G.A. Sundareswaran K.S. Farrar D.J. Slaughter M.S. HeartMate II Clinical InvestigatorsOutcomes in advanced heart failure patients with left ventricular assist devices for destination therapy.Circ Heart Fail. 2012; 5: 241-248Crossref PubMed Scopus (278) Google Scholar The time and duration of LVAD support the of of J.K. Naftel D.C. Pagani F.D. Kormos R.L. Stevenson L.W. Miller J. Young INTERMACS a Heart Full Text Full Text PDF PubMed Scopus Google Scholar This study was as a for the outcomes of LVAD therapy at centers transplantation or of MCS A has been that a of LVAD implantation after commercial approval have a on G.C. Stevenson L.W. Keeping left ventricular assist device acceleration on track.Circulation. 2011; 123 (discussion 1568): 1559-1568Crossref PubMed Scopus (50) Google Scholar resources to heart failure care at all of centers are necessary to outcomes in the heart failure M. D.E. J. profile of heart failure programs that heart and mechanical circulatory support device a report of the Heart Failure and Heart Failure and and Heart Failure of Am Coll Cardiol. 2011; 57: Full Text Full Text PDF PubMed Scopus Google Scholar The of the LVAD programs at the MCS and at centers at heart transplantation and MCS were as of the In for DT by the for and an MCS center is to a of LVAD a All of the MCS centers have for and DT or are in the of LVAD at the MCS centers a in the overall management of as and are necessary for the care of LVAD patients. patients with heart failure with LVAD support are to in and and to the In to with a transplantation center is an in MCS center All MCS centers have agreements with transplantation centers to ensure appropriate and transplantation for those patients who support as BTT. Most of the heart failure population in the United has to LVAD Patients with heart failure are throughout the United and care is provided by centers in a of The to LVAD therapy is the of and the of the number and of the most transplantation centers that LVAD therapy are not adequate to the population of patients with heart M.S. destination therapy to Heart J. Google Scholar of LVAD therapy to nontransplantation centers is necessary to the number of patients with heart A of this study is that patients at the MCS centers not to those from the clinical or to patients in the INTERMACS an analysis of that is beyond the of this The retrospective analysis of registry data have in the and of a in of all from implantation to and and of data is not as as in Food and Drug clinical The and from for their with statistical analysis and The have of to