Beyond Mortality - Significant Morbidity and Function Decline Follows Left Ventricular Assist Device Exchange

Abstract

Introduction The operative exchange of a durable left ventricular assist device (LVAD) has become more commonplace. While most of the literature has focused on survival and surgical technique, little is known about the impact of LVAD exchange on patient morbidity and functional status. Hypothesis Morbidity and re-hospitalization will be common following LVAD exchange, while functional status will decline. Using each patient as their own control, there will be increased post-operative complication, morbidity, and 90-day readmission in comparison to the initial implant. Methods The medical record of all patients receiving a durable LVAD at our institution between January 2007 and December 2017 were reviewed. Those patients requiring LVAD exchange were included in this analysis. Patients were following for 1 year or until death or transplantation. Results Between January 2007 and December 2017, 341 patients underwent primary LVAD implantation. A total of 17 patients (5%) required device exchange, with indications including: pump thrombosis/hemolysis (47%), driveline injury or malfunction (29.4%), infection (11.8%), LVAD failure/stoppage (5.9%), and cannula malposition (5.9%). One-year mortality after LVAD exchange was 29.4% with a 50% mortality in those who had pump thrombosis as the indication for exchange, and 100% mortality in those with an ischemic etiology to their heart failure. Eight patients (47%) required a total of 12 hospital readmissions within 90 days of discharge following LVAD exchange. Indications for re-hospitalization included infection, post-operative wound management, and organ failure. Nine patients (53%) had at least one significant event within 90 days of device exchange, including cardiogenic shock, right ventricular failure, recurrent thrombosis, prolonged renal impairment requiring dialysis, gastrointestinal bleeding, stroke, and infection. Of the patients with a documented NYHA class pre- and post-device exchange (12 of 17), the majority had either no improvement or had a decline in functional status. Analysis is being performed to use each patient as their own control and compare post-operative complications, morbidity, and 90-day readmission in the initial implant versus LVAD exchange. Conclusions Not only does LVAD exchange lead to increased mortality, it is also associated with increased morbidity and re-hospitalization. Additionally, functional status may fail to improve after operative intervention. For a group of patients who routinely rank quality of life over survival, the unintended consequences of LVAD pump exchange mandate further exploration.