Background: Continuous-flow left ventricular assist devices (CF-LVADs) have become a standard treatment choice in advanced heart failure patients. We hypothesized that practice patterns with regards to CF-LVAD utilization vary significantly among transplant centers and impact waitlist outcomes.

Methods and Results: The United Network for Organ Sharing registry was queried to identify adult patients who were waitlisted for heart transplantation (HT) between 2008 and 2015. Each patient was assigned a propensity score based on likelihood of receiving a durable CF-LVAD before or while waitlisted. The primary outcomes of interest were death or delisting for worsening status and HT at 1 year. A total of 22 863 patients from 92 centers were identified. Among these, 9013 (39.4%) were mechanically supported. CF-LVAD utilization varied significantly between and within United Network for Organ Sharing regions. Freedom from waitlist death or delisting was significantly lower in propensity-score–matched patients who were mechanically supported versus medically managed (83.5% versus 79.2%; P<0.001). However, cumulative incidence of HT was also lower in mechanically supported patients (53.3% versus 63.6%; P<0.001). Congruous mechanical and medical bridging strategies based on clinical risk profile were associated with lower risk of death or delisting (hazard ratio, 0.88; P=0.027) and higher likelihood of HT (hazard ratio, 1.14; P<0.001).

Conclusions: CF-LVAD utilization may lower waitlist mortality at the expense of lower likelihood of HT. Decision to use CF-LVAD and timing of transition should be individualized based on patient-, center-, and region-level risk factors to achieve optimal outcomes.

背景：连续流式左心室辅助设备（CF-LVAD）已成为晚期心力衰竭患者的标准治疗选择。我们假设，关于CF-LVAD利用率的实践模式在移植中心之间存在显着差异，并且会影响候补名单的结果。

方法和结果：查询美国器官共享网络注册中心，以识别在2008年至2015年之间等待心脏移植（HT）的成年患者。根据之前或之后接受持久性CF-LVAD的可能性，为每个患者分配倾向得分。在候补名单中。感兴趣的主要结局是死亡或因病情恶化而除名，并在1年时出现HT。共鉴定了来自92个中心的22863名患者。其中，9013（39.4％）被机械支撑。在器官共享区域的联合网络之间和内部，CF-LVAD的利用率差异很大。机械支持的倾向评分匹配患者与药物治疗的患者相比，免于等待死亡或退名的自由度显着降低（83.5％对79.2％；P<0.001）。然而，在机械支持的患者中，HT的累积发生率也较低（53.3％对63.6％；P <0.001）。基于临床风险状况的机械和医学衔接策略相结合，可降低死亡或退市的风险（危险比，0.88；P = 0.027）和发生HT的可能性更高（危险比，1.14；P <0.001）。

结论： CF-LVAD的利用可以降低候诊者的死亡率，但以降低HT的可能性为代价。应根据患者，中心和区域级别的风险因素，个性化使用CF-LVAD的决定和过渡时间，以实现最佳结果。