Background

Multicenter data on long term survival following LVAD implantation that make use of contemporary definitions of RV failure are limited. Furthermore, traditional survival analyses censor patients who receive a bridge to heart transplant. Here we compare the outcomes of LVAD patients who develop post-operative RV failure accounting for the transitional probability of receiving an interim heart transplantation.

Methods

We use a retrospective cohort of LVAD patients sourced from multiple high-volume centers based in the United States. Five- and ten-year survival accounting for transition probabilities of receiving a heart transplant were calculated using a multi-state Aalen Johansen survival model.

Results

Of the 897 patients included in the study, 238 (26.5%) developed post-operative RV failure at index hospitalization. At 10 years the probability of death with post-op RV failure was 79.28% vs 61.70% in patients without (HR 2.10; 95% CI 1.72 – 2.57; p = < .001). Though not significant, patients with RV failure were less likely to be bridged to a heart transplant (HR 0.87, p = .4). Once transplanted the risk of death between both patient groups remained equivalent; the probability of death after a heart transplant was 3.97% in those with post-operative RV failure shortly after index LVAD implant, as compared to 14.71% in those without.

Conclusions and relevance

Long-term durable mechanical circulatory support is associated with significantly higher mortality in patients who develop post-operative RV failure. Improving outcomes may necessitate expeditious bridge to heart transplant wherever appropriate, along with critical reassessment of organ allocation policies.

中文翻译：

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LVAD 后右心室衰竭患者的长期生存：具有心脏移植竞争结果的多状态模型

 背景

利用当代 RV 衰竭定义的 LVAD 植入后长期生存的多中心数据有限。此外，传统的生存分析会审查接受心脏移植的患者。在这里，我们比较了术后发生右心室衰竭的 LVAD 患者的结果，考虑了接受临时心脏移植的过渡概率。

 方法

我们使用来自美国多个大容量中心的 LVAD 患者回顾性队列。使用多状态 Aalen Johansen 生存模型计算了考虑接受心脏移植的转变概率的五年和十年生存率。

 结果

在该研究纳入的 897 名患者中，238 名患者 (26.5%) 在首次住院期间出现术后右心室衰竭。 10 年时，术后 RV 衰竭的患者死亡概率为 79.28%，而没有术后 RV 衰竭的患者为 61.70%（HR 2.10；95% CI 1.72 – 2.57； p = < .001）。尽管不显着，但右心室衰竭患者接受心脏移植的可能性较小（HR 0.87， p = .4）。一旦移植，两组患者的死亡风险保持相等；植入左心室辅助装置 (LVAD) 后不久出现术后 RV 衰竭的患者，心脏移植后死亡的概率为 3.97%，而没有植入 RVAD 的患者，死亡概率为 14.71%。

结论和相关性

长期持久的机械循环支持与术后右心室衰竭患者的死亡率显着升高相关。改善结果可能需要在适当的情况下迅速过渡到心脏移植，并对器官分配政策进行严格的重新评估。