Assessing Barriers to Heart Transplantation for Bridge to Decision and Long Term Left Ventricular Assist Device Recipients

Introduction Left ventricular assist device (LVAD) therapy may serve as bridge to heart transplantation (HT) for patients whose initial implant strategy is bridge-to decision (BTD) or destination/long-term therapy (LT). Data capturing modifiable barriers or contraindications to HT and their evolution after LVAD therapy are lacking. Methods We conducted a single-center observational retrospective cohort study of patients with barriers to HT undergoing LVAD implantation as BTD or LT between 1/1/2014 and 12/31/2021. Initial barriers were classified as modifiable or nonmodifiable. We tracked barrier resolution, development of new barriers after LVAD, and receipt of HT with minimum 2-year follow-up. Results Of 313 patients, 215 (69%) had modifiable barriers at time of LVAD. Sixty percent (118 of 196 with modifiable barriers surviving past index LVAD implant) resolved their initial barriers during follow up. Of these 118, 31% received HT, while 53% developed new barriers post-LVAD. Black patients more frequently had modifiable initial barriers compared to non-Black patients (72% vs 58%, p=0.02). The most common initial modifiable barriers were substance use disorder (SUD, 21%), body mass index (BMI, 18%), modifiable comorbidities (uncontrolled diabetes, cancer, 17%), and psychosocial barriers (12%). Post-LVAD, BMI followed by SUD and modifiable comorbidities were the most frequent barriers successfully overcome. Frailty emerged as the most prevalent new barrier post-LVAD (43%) followed by modifiable comorbidities (20%) and SUD (19%). Conclusion Barriers to HT are dynamic in the journey of the BTD/LT LVAD patient. Substance abuse, BMI, modifiable comorbidities, psychosocial barriers, and post-LVAD frailty emerged as areas in need of multidisciplinary intervention to potentially increase access to HT.