All ETDs from UAB

Advisory Committee Chair

Gerald McGwin

Advisory Committee Members

James K Kirklin

Emily B Levitan

Charity J Morgan

Document Type

Dissertation

Date of Award

2018

Degree Name by School

Doctor of Philosophy (PhD) School of Public Health

Abstract

Mechanical circulatory support (MCS) is a rapidly evolving field. This dissertation describes trends in patient selection, device utilization, and outcomes for adult and pediatric patients receiving MCS in the United States by examining data from two national registries. Trends in adult MCS device recipients and their support outcomes were evaluated using data from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS), a national registry collecting detailed information for patients implanted with Food and Drug Administration (FDA)-approved durable MCS devices. Between June 2006 and December 2016, INTERMACS enrolled more than 19,000 patients. During this time, the widespread use of devices has expanded from a bridge-to-transplant to destination therapy in which the device is used for long term support as an alternative to transplant. This has resulted in use of devices in older patients with more comorbidities, proportionally less patients receiving transplants, and longer times on support. Currently, the majority of patients receive continuous flow ventricular assist devices (CF-VADs). For adult patients receiving CF-VADs, survival has improved in the most current era. This is observed in the crude (unadjusted) Kaplan-Meier survival estimates as well as multiphase parametric hazard modeling adjusted for pre-implant risk factors. Trends in pediatric MCS device recipients and their support outcomes were evaluated using data from the Pediatric Arm of the Interagency Registry for Mechanically Assisted Circulatory Support (PEDIMACS) which included 429 children enrolled between September 2012 and March 2017. Enrollment in the registry has increased, possibly indicating a growth in the application of pediatric MCS. Patient characteristics have remained stable. Device selection, however, is shifting based on patient age/size and patients are spending more time on device. Changing pediatric patient risk profiles highlight the need for risk-adjusted outcomes for evaluating pediatric MCS. By utilizing national registries, these analyses provide the most detailed description to date of MCS use in patients in the United States. The results provide evidence of continued the improvements in the outcomes for patients receiving CF-VADs. This information provides clearer expectations of support outcomes and will be useful for patient and physician decision making.

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