Reversibility of Fixed Pulmonary Hypertension with LVADs as a Bridge to Candidacy Strategy for Heart Transplantation: A Systematic Review and Meta-Analysis

Introduction Current guidelines recommend against listing for heart transplantation (HTx) if there is evidence of fixed pulmonary hypertension (fPH) given that these patients tend to have poor post-HTx outcomes. The purpose of this study is to investigate the feasibility of left ventricular assist device (LVAD) implantation as a bridge to candidacy (BTC) in patients with fPH through a systematic review and meta-analysis of published literature. Methods We systematically searched Medline, Embase & the Cochrane library through December 31, 2018 for studies reporting patients with fPH treated with LVADs as a BTC for HTx. The primary outcome analyzed percentage of patients within each cohort achieving reversibility of pulmonary hemodynamics and the secondary endpoint was the time necessary to improve hemodynamics. Studies meeting inclusion criteria were assessed with the Newcastle-Ottawa tool. We performed a random-effects meta-analysis using pooled proportions and heterogeneity was examined using I2 statistics. All statistical analyses were carried out using Stata/IC 14.2. Results A total of 8 studies (6 retrospective cohorts and 2 prospective cohorts) including 207 patients (89% male, mean age 49.46 years) formed part of our analysis. Continuous flow LVADs were used in 176 patients (79%). Our meta-analysis showed 97% reversal of fPH (95% CI, 88-100%) (Figure 1). The mean response time was of 5.33 months (95% CI: 3.67-7.00). Out of the initial 207 patients, 80% (95% CI:61-98%) were effectively bridged to receive a HTx. Conclusions Our findings show that in patients unable to be listed for HTx due to fPH, a BTC strategy with LVAD implantation is associated with improvement in pulmonary hemodynamics with a mean response time of approximately 5 months. Further studies evaluating long-term outcomes in these patients are warranted.