Indications for LVAD Explant and Predictors of Mortality after Explant in IMACS

Abstract

As support durations increase, patients' risk for requiring LVAD device explant (Exp) to address complications also increases. The aims of this analysis were to better understand indications and outcomes associated with LVAD explant. Patients enrolled into IMACS requiring continuous flow LVAD explant (Exp) for nontransplant indications were identified. Survival in those with and without device Exp and by Exp indication were estimated with Kaplan-Meier methods, and correlates of mortality within the combined Exp dysfunction+other cohort were examined with Cox Regression. Of 16,842 patients on CF-LVAD in IMACS, 1,579 patients underwent LVAD Exp. Indications for Exp included non-urgent (83.1%) and urgent (1.5%) device malfunction; LV recovery (12.0%); elective (0.25%) and urgent (0.32%) pump thrombosis; and "other" (3.1%). Median time to explant for "other" causes was shortest at 1.2 [0.0, 14.5] months compared with 8 [2.6,17] months for device dysfunction-Exp and 10.9 [7.5,16.3] months for recovery-Exp (p<0.05). Early survival in patients undergoing Exp for any reason was better than those without a history of Exp (figure), findings likely related to statistical "survivorship bias" and excellent survival in recovery patients. Patients undergoing Exp for device malfunction-Exp (61±1.7%) or other causes (62±8.2%) had clinically similar 3 year survivals, but survivals were worse than those undergoing Exp for recovery (91±4.9%). Age at implant (HR 1.016 [1.008-1.024] per year), centrifugal flow device (HR 1.6 [1.2-2.1]), prior cardiac surgery (HR 1.4 [1.1-1.7]) and Profile 1-2 (HR 1.3 [1.0-1.5]) were correlates for mortality in those undergoing Exp for device dysfunction or other indications. Survival was similar for those with device Exp due to malfunction and other indications in IMACS. Older patients and those with a history of multiple sternotomies do poorly after Exp. In the elderly, shared decision-making and engagement of palliative care should be undertaken prior to Exp.