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Our research, published in the Journal of Cardiac Failure – Intersections, finds that most patients with modifiable barriers to heart transplant can resolve them with team-based support after LVAD.
For someone living with advanced heart failure, being told a heart transplant is impossible can be devastating. Often, ineligibility for a transplant is based on a specific medical or lifestyle barrier that makes the surgery risky or the long-term outcome uncertain.
Data shows heart failure contributed to more than 425,000 deaths in 2022, or 45% of all cardiovascular deaths in the U.S. These sobering figures highlight the importance of helping more people become transplant eligible—though the journey is anything but straightforward.
Our research, published in the Journal of Cardiac Failure – Intersections, highlights modifiable barriers to heart transplantation that can be resolved with teamwork and dedicated care. We explored how a mechanical heart pump known as a left ventricular assist device (LVAD) can create a window of opportunity to overcome these barriers and help more people become healthy enough for a heart transplant.
The dynamic journey to a heart transplant.
A heart transplant is the gold standard for treating advanced heart failure, but donor hearts are a scarce resource. Patients must undergo a rigorous evaluation to make sure they’re healthy enough to survive surgery and thrive with a new heart.
Barriers that can make a patient ineligible for a heart transplant can include:
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Age: Transplant surgery can have a higher risk of complications for people over age 70.
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Body mass index (BMI): A BMI over 35 can significantly increase the likelihood of complications.
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Substance use: Active tobacco or drug use could damage a new organ.
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Uncontrolled chronic illness: Conditions such as diabetes must be well controlled so a patient can be stable enough for the medications used after transplant.
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Psychosocial factors: Without adequate housing or a dedicated caregiver, for example, the complex recovery process can be difficult.
Some of these barriers are beyond a patient’s control, such as age and certain severe illnesses. Others, like BMI or substance use, can be changed. These are called modifiable barriers. In these cases, an LVAD can help us delay—a “bridge to decision.” The LVAD is a mechanical pump that takes over the heart’s work, allowing the patient to remain alive while we work together to address modifiable barriers.
Examining patients’ real-world experience.
To understand how barriers to transplant evolve, we conducted a retrospective cohort study of 313 adult patients who received an LVAD as a bridge to decision at MedStar Washington Hospital Center between 2014 and 2021.
Studies that examine patient records from large, national databases can miss the fine details of a patient’s personal journey. We chose to study patients at one hospital so we could better examine the specific hurdles they face and the social factors that influence their health.
Extracting the demographics, clinical variables, and outcomes from anonymous patient records enabled us to learn more about whether patients could move from ineligible to eligible for transplant while living with LVAD.
Our results were encouraging. After statistical analysis, we found that 60% of patients who had an LVAD implanted were able to resolve modifiable barriers to transplant, opening the door to a new heart.
The transplant journey’s evolving hurdles.
Our research also found that an individual patient’s transplant journey is rarely a straight line. After receiving the LVAD, 53% of the patients we studied developed new challenges. The most common of these was frailty, which affected 43% of patients after implantation. This finding highlights the importance of proactive exercise and nutrition.
To better understand patients’ social context, our study also examined racial disparities. We found that Black patients were more likely than non-Black patients to have modifiable barriers (72% vs 58%), the most common of which was high BMI. This is tied to social determinants of health—factors such as access to healthy food and stable resources.
Recognizing these differences enables us to tailor our support systems better to ensure as many patients as possible have the opportunity for a life-saving heart transplant.
Related: Read “Study Explores Device to Give Early Warning of Worsening Heart Failure.”
The power of team-based support.
Our research highlights that LVAD is more than a powerful piece of technology: It’s an opportunity to help patients overcome barriers successfully. A team of specialists collaborating with the patient can achieve the best results.
This multidisciplinary team can include:
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Dietitians and bariatric surgeons: For patients with a high BMI, tools such as GLP-1 RA medications and a dedicated partnership with our colleagues in bariatric surgery can help.
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Rehabilitation specialists: We work together with physical therapists and cardiac rehabilitation teams to address the physical weakness that can come along with long-term heart failure.
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Social workers and counselors: These experts can help patients secure stable housing and build the caregiver support networks necessary for a successful transplant.
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Specialized clinicians: We partner with a broad spectrum of colleagues, including endocrinologists, to stabilize diabetes.
An opportunity for better health.
Today’s LVAD devices, such as the Heartmate 3, can typically power the heart for five years, giving patients a reliable path forward while they wait for a transplant.
This research helps us identify the chance for providers to help patients with advanced heart failure, even if an initial evaluation suggests they are not a candidate for a transplant right away. The LVAD could open a window of opportunity to support, monitor, and reassess these patients, helping them overcome modifiable barriers to get a second chance at a transplant.
The patient’s journey to transplant is dynamic. It can be a marathon that requires patience, a multidisciplinary team, and a proactive mindset. Helping patients address modifiable barriers can turn the bridge to decision-making into a bridge to a longer, healthier life.
