Bridge or Burden? Heart Transplant Outcomes Following Left Ventricular Assist Device Explant in the Contemporary Allocation Era.
TL;DR
These findings suggest LVAD explant identifies a higher-risk transplant phenotype shaped by surgical burden, device-associated physiologic effects, and allocation-era transplant timing, rather than by intrinsic device-related risk alone.
Abstract
Background
Whether left ventricular assist device (LVAD) explant during heart transplantation confers additional risk remains unsettled in the contemporary allocation era.
Methods
Heart transplant recipients at a single center (January 2020-December 2024) were retrospectively reviewed. Patients undergoing multi-organ transplants, with congenital heart disease, ≥2 prior sternotomies, non-HeartMate 3 LVADs or pre-transplant ECMO were excluded. Recipients were grouped as primary sternotomy, non-LVAD redo sternotomy, or LVAD explant. Outcomes included transfusions, vasoplegia, and 30-day, 1-year, and 2-year mortality. IPTW-weighted logistic regression and Cox models assessed vasoplegia and mortality.
Results
Among 432 recipients (primary sternotomy 237; non-LVAD redo sternotomy 90; LVAD explant 105), transfusion volumes increased stepwise intraoperatively and 48 hours postoperatively (both p<0.001). Vasoplegia differed across cohorts (12.1% vs 24.3% vs 22.9%; p=0.014); after IPTW adjustment, LVAD explant remained associated with higher odds versus primary sternotomy (OR 2.2 [1.1-4.4]; p=0.03). Unadjusted survival declined across groups at 1 year (98.3% vs 93.3% vs 87.6%, p<0.001) and 2 years (95.0% vs 89.1% vs 85.2%, p=0.003). Versus primary sternotomy, LVAD explant had higher adjusted hazards of death at 1 year (HR 5.8 [1.8-19], p=0.003) and 2 years (HR 2.9 [1.3-6.7], p=0.01). In an exploratory lower-risk LVAD explant subgroup (n=37), observed mortality differences were attenuated.
Conclusions
LVAD explant during heart transplant was associated with greater transfusions, vasoplegia, and early-to-intermediate mortality compared with primary sternotomy. These findings suggest LVAD explant identifies a higher-risk transplant phenotype shaped by surgical burden, device-associated physiologic effects, and allocation-era transplant timing, rather than by intrinsic device-related risk alone.