Long-term survival on LVAD support: Device complications and end-organ dysfunction limit long-term success

Abstract

Preoperative variables can predict short term left ventricular assist device (LVAD) survival, but predictors of extended survival remain insufficiently characterized. Patients undergoing LVAD implant (2012-2018) in the Intermacs registry were grouped according to time on support: short-term (<1 year, n=7,483), mid-term (MT, 1-3 years, n=5,976) and long-term (LT, ≥3 years, n=3,015). Landmarked hazard analyses (adjusted hazard ratio, HR) were performed to identify correlates of survival after 1 and 3 years of support. After surviving 1 year of support, additional LVAD survival was less likely in older (HR 1.15 per decade), Caucasian (HR 1.22) and unmarried (HR 1.16) patients (p < 0.05). After 3 years of support, only 3 preoperative characteristics (age, race, and history of bypass surgery, p < 0.05) correlated with extended survival. Postoperative events most negatively influenced achieving LT survival. In those alive at 1 year or 3 years, the occurrence of postoperative renal (creatinine HR MT=1.09; LT HR=1.10 per mg/dl) and hepatic dysfunction (AST HR MT=1.29; LT HR=1.34 per 100 IU), stroke (MT HR=1.24; LT HR=1.42), infection (MT HR=1.13; LT HR=1.10), and/or device malfunction (MT HR=1.22; LT HR=1.46) reduced extended survival (all p ≤ 0.03). Success with LVAD therapy hinges on achieving long term survival in more recipients. After 1 year, extended survival is heavily constrained by the occurrence of adverse events and postoperative end-organ dysfunction. The growth of destination therapy intent mandates that future LVAD studies be designed with follow up sufficient for capturing outcomes beyond 24 months.