Blood Conservation Strategy at Time of Left Ventricular Assist Device Placement Improves Survival

Abstract

Bleeding is the most common complication of left ventricular assist device (LVAD) placement. However, excessive transfusion has been linked to heart failure, stroke, and alloimmunization. We compared 90-day outcomes in patients receiving a blood conservation (BCS) versus liberal transfusion strategy during surgery and the subsequent 24 hours. 173 LVAD implants at a single center between June 2011 and September 2018 were reviewed. Due to incomplete data, 3 patients were excluded. The BCS (≤1 packed red blood cell (pRBC)) was employed in 56/170 patients. In the liberal group, 41 received 2-5 units, 24 received 6-10 units, 24 received 11-15 units, and 25 received ≥15 units of PRBC. Anti-platelet use was equal across groups whereas anticoagulants were more readily used in the conservative group (55 vs 38%, p=0.04) at implantation. The liberal group had greater use of circulatory support devices (47 vs 29%, p=0.02) whereas the BCS group had larger ventricular size. Pre-operative laboratory values were similar among groups except for hemoglobin g/dL (12.6 conservative vs 11.6 liberal, p=0.02). Both the length of hospital and ICU stay were lower in the BCS group (17 vs 24 days, p<0.001 and 9 vs 12 days, p=0.02). Bleeding events (p-0.02) and reoperation were more frequent in the liberal group (13 vs 32 %, p=0.007). No difference between stroke, infection and right ventricular assist device use rates were seen. 90-day mortality was significantly higher in the liberal group (p=0.03). However, multivariate analysis did not show a significant benefit of the BCS despite trend towards survival with a crude HR 2.23 (0.86-5.82, p=0.10) and adjusted HR 2.21 (0.82-5.75, p=0.10). BCS at time of LVAD implant is associated with improved early survival. Identified transfusion triggers and standardized transfusion protocols for LVAD patients have the potential to reduce blood product utlization.