Predictors of Failure to Rescue After Left Ventricular Assist Device Implantation

Abstract

<h3>Purpose</h3> Failure to rescue (FTR), defined as death after a complication, is an established hospital quality metric for coronary and valve surgery. While prior work has documented interhospital variability in FTR after durable left ventricular assist device (LVAD), less is known about patient and complication-specific predictors of FTR in this setting. <h3>Methods</h3> Patients undergoing primary LVAD implantation from 2012-2017 were selected from the INTERMACS database. The cohort was divided into two groups and compared based on patient survival following complications and FTR. FTR was defined as patient in-hospital mortality after experiencing at least one of the following major complications: severe right heart failure, respiratory failure, renal failure requiring dialysis, major infection, device malfunction, and bleeding requiring reoperation. Multivariable logistic regression was used to evaluate both pre-operative patient and complication specific predictors of FTR. Stepwise selection was used to arrive at the final model. <h3>Results</h3> Of the 13,617 patients in the sample, 4,839 (35.5%) experienced a major complication of which 854 (17.6%) died (i.e., FTR). Patients in the FTR group were more likely to be older (61.3 +/- 11.5 vs 56.9 +/-12.9, p<0.001), INTERMACS Profile 1 (30.9% vs 20.9%, p<0.0001), and Destination Therapy (55.6% vs 48.3%, p=0.0003). Significant predictors of FTR included: a history of prior CABG (OR = 1.54, CI95%: 1.31-1.82), valve surgery (OR = 1.50, CI95%: 1.07-2.11), preoperative dialysis (OR = 2.29, CI95%: 1.70-3.08) and preoperative ECMO (OR=4.27, CI95%: 3.01-6.04). Patients developing right heart failure had the highest complication-specific FTR rate (75.3%) followed by reintubation (45.1%), Table 1. <h3>Conclusion</h3> This study identified four significant preoperative predictors of FTR after durable LVAD placement. Future work should focus on identifying patients at highest risk of FTR, as well as early recognition and management of complications.