Mandeep R. Mehra, MD, on Clinical Outcomes With LVAD Use by Bridge to Transplant or Destination Therapy Intent
In a new study, investigators determined whether clinical outcomes in the MOMENTUM 3 trial differed by preoperative categories of bridge to transplant (BTT) or bridge to transplant candidacy (BTC) vs destination therapy (DT).
Cardiology Consultant reached out to lead investigator, Mandeep R. Mehra, MD, who is the executive director of the Center for Advanced Heart Disease at Brigham and Women’s Hospital in Boston, Massachusetts, for more insight on this team research.
CARDIO CON: In patients with advanced heart failure, do outcomes with left ventricular assist device (LVAD) implantation differ by the initial intended goal?
Mandeep Mehra: In general, this distinction of categories was established precisely because the destination therapy patients tended to have inferior outcomes compared with those deemed to be a bridge to transplantation, in the era of the older devices. With the advent of the newer pumps, we now have improvements in the outcomes such that the categories seem meaningless.
CARDIO CON: Which devices or types of devices were part of the trial, and which ones performed the best in terms of patient outcomes?
MM: This study compared a new LVAD—the HeartMate 3 pump—to the older HeartMate II device. This new device is uniquely engineered to be small, fit entirely in the chest, not disrupt red blood cells as they pass through the pump, is frictionless since it is based on magnetically levitated technology, and has an intrinsic pulse built into it. This pump was shown to be markedly superior in performance and clinical outcomes to the older-generation pump in this trial.
CARDIO CON: How were adverse events, functional status, and quality of life affected throughout the trial?
MM: The newer HeartMate 3 pump improved survival free of a disabling stroke and need for replacement of a malfunctioning pump in the primary analysis of the trial. What was remarkable is that survival free of a stroke (either disabling or nondisabling) was reduced significantly and equally among HeartMate 3–treated patients irrespective of the category of either bridge to transplant or destination therapy.
CARDIO CON: What are the top 3 key take-home messages from the MOMENTUM 3 trial for cardiologists and interventional cardiologists?
MM: The treatment efficacy and safety of HeartMate 3 vs HeartMate II was similar in both BTT/BTC and DT groups:
- HeartMate 3 was superior to HeartMate II for survival free of disabling stroke or reoperation to replace or remove a malfunctioning pump at 2 years.
- HeartMate 3 use resulted in significant reductions in pump thrombosis, stroke, and gastrointestinal bleeding.
Therapeutic intent is dynamic and can change over time with transplant-ineligible patients qualifying for a transplant after time in support with the LVAD. Therapeutic intent categorizations based on transplant eligibility should be abandoned in favor of a single pre-implant strategy: to extend the survival and improve the quality of life of patients with medically refractory heart failure.
Reference
- Goldstein DJ, Naka Y, Horstmanshof D, et al. Association of clinical outcomes with left ventricular assist device use by bridge to transplant or destination therapy intent: the Multicenter Study of MagLev Technology in Patients Undergoing Mechanical Circulatory Support Therapy With HeartMate 3 (MOMENTUM 3) randomized clinical trial [published online January 15, 2020]. JAMA Cardiol. http://jamanetwork.com/article.aspx?doi=10.1001/jamacardio.2019.5323.