Rising Total Bilirubin After CF-LVAD Implantation Is Highly Associated With Post Left Ventricular Assist Device Mortality

Abstract

Introduction Elevated total bilirubin levels are common after left ventricular assist device placement (LVAD). The association between bilirubin trend after LVAD implantation and post LVAD mortality has not been described. Hypothesis Rising bilirubin (slope) will be highly associated with mortality after CF-LVAD implantation. Methods The study cohort included adults with first time, continuous flow (CF) LVAD implantation at a single center. Patients with enough laboratory data to allow a total bilirubin slope to be calculated between post-operative day 1-10 were included in the analysis. The primary outcome was 60-day mortality. To test the association between slope of total bilirubin and 60-day mortality after CF-LVAD, a multivariable logistic regression was performed. Results The study cohort consisted 358 patients. 82% were male, 57 % were bridge to transplant (BTT), and 19 % received HeartMate 3 devices. The Figure demonstrates total bilirubin trend among patients, coded by 60-day mortality group. Each 1 mg/dl increase in total bilirubin between post-operative days 1-10 was associated with a 42 % increase in the odds of mortality at 60 days (adjusted OR 1.42, 95 % CI 1.75-2.25, p <0.0001). The model was adjusted for INTERMACS profile, right atrial pressure, age, renal function, device type, and BTT status. Pre-operative right atrial pressure was highest among patients with the largest decline in total bilirubin after LVAD. No statistically significant difference was detected between other baseline characteristics and post LVAD bilirubin slope tertiles. Conclusions A rising bilirubin after LVAD is highly predictive of post-operative mortality. Further work will be needed to determine what pre-operative or intra-operative variables predict the development of this concerning pattern of organ failure. Elevated total bilirubin levels are common after left ventricular assist device placement (LVAD). The association between bilirubin trend after LVAD implantation and post LVAD mortality has not been described. Rising bilirubin (slope) will be highly associated with mortality after CF-LVAD implantation. The study cohort included adults with first time, continuous flow (CF) LVAD implantation at a single center. Patients with enough laboratory data to allow a total bilirubin slope to be calculated between post-operative day 1-10 were included in the analysis. The primary outcome was 60-day mortality. To test the association between slope of total bilirubin and 60-day mortality after CF-LVAD, a multivariable logistic regression was performed. The study cohort consisted 358 patients. 82% were male, 57 % were bridge to transplant (BTT), and 19 % received HeartMate 3 devices. The Figure demonstrates total bilirubin trend among patients, coded by 60-day mortality group. Each 1 mg/dl increase in total bilirubin between post-operative days 1-10 was associated with a 42 % increase in the odds of mortality at 60 days (adjusted OR 1.42, 95 % CI 1.75-2.25, p <0.0001). The model was adjusted for INTERMACS profile, right atrial pressure, age, renal function, device type, and BTT status. Pre-operative right atrial pressure was highest among patients with the largest decline in total bilirubin after LVAD. No statistically significant difference was detected between other baseline characteristics and post LVAD bilirubin slope tertiles. A rising bilirubin after LVAD is highly predictive of post-operative mortality. Further work will be needed to determine what pre-operative or intra-operative variables predict the development of this concerning pattern of organ failure.