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Published on: July 18, 2014
High-volume centers achieve superior outcomes in left ventricular assist device explant-heart transplantation
Catherine L B McGeoch1, Clayton J Rust1, Reshma Kodimerla1
1Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, Ga.
Insights
High-volume centers improve outcomes for patients undergoing left ventricular assist device (LVAD) explantation and orthotopic heart transplantation (OHT). This approach reduces complications and increases patient survival rates.
Area of Science:
- Cardiology
- Transplant Surgery
- Medical Devices
Background:
- Left ventricular assist device (LVAD) explantation during orthotopic heart transplantation (OHT) is associated with significant perioperative risks.
- Institutional surgical volume is a potential factor influencing outcomes in this complex procedure.
Purpose of the Study:
- To investigate the impact of institutional operative volume on patient outcomes after LVAD explantation and OHT.
- To compare outcomes between high-volume and low-volume centers performing LVAD explant-OHT.
Main Methods:
- Analysis of adult patients undergoing LVAD explant-OHT from 2011-2024 using the OPTN/UNOS registry.
- Centers stratified into high-volume and low-volume groups based on surgical case numbers.
- Primary outcome: 1-year survival; secondary outcomes: graft failure, ischemic time, dialysis, stroke, and length of stay.
Main Results:
- High-volume centers (performing 31.3% of cases) showed significantly decreased ischemic time, lower postoperative dialysis rates, and shorter hospital stays.
- Graft failure was less common, and 1-year survival rates were higher at high-volume centers (81.6% vs 76.1%).
- Low-volume center status was an independent predictor of increased mortality (HR, 1.28).
Conclusions:
- Higher institutional operative volume is associated with superior 1-year survival following LVAD explant-OHT.
- High-volume centers demonstrate improved perioperative outcomes, including reduced complications and shorter hospitalizations.
- Patient selection for LVAD explant-OHT should consider center volume for optimal results.
Background:
Left ventricular assist device (LVAD) explantation at the time of orthotopic heart transplantation (OHT) carries increased perioperative risks. This study examined whether institutional operative volume influences outcomes following LVAD explant-OHT in a contemporary national cohort.
Methods:
Adult patients who underwent LVAD explantation with OHT between 2011 and 2024 were identified in the Organ Procurement and Transportation Network/United Network for Organ Sharing registry. Using a rank-order method based on surgical volume, centers were stratified as either high volume or low volume. The primary outcome was 1-year survival; secondary outcomes included graft failure, ischemic time, dialysis, stroke, and hospital length of stay. Kaplan-Meier and Cox regression analyses were performed to assess survival and predictors of mortality.
Results:
A total of 2863 patients across 121 centers were analyzed. Eight high-volume centers performed 31.3% (897 cases) of all LVAD explant-OHTs. Baseline characteristics, including heart failure etiology and LVAD device type, were similar in the 2 groups. High-volume centers demonstrated decreased ischemic time (mean, 3.1 ± 1.3 hours vs 3.5 ± 1.4 hours; P < .001), a lower rate of postoperative dialysis (12.7% vs 15.4%; P = .023), and shorter length of stay (mean, 22.8 ± 26.6 days vs 25.9 ± 31.3 days; P = .006) compared to low-volume centers. Graft failure was less common at high-volume centers (24.2% vs 28.8%; P = .011). One-year survival rate (81.6% vs 76.1%; P = .001) and median survival (4.93 years vs 4.00 years; P = .018) were greater at high-volume centers. Multivariable analysis identified low-volume center status as an independent predictor of higher mortality (hazard ratio, 1.28; 95% confidence interval, 1.10-1.50; P = .002).
Conclusions:
High-volume centers were associated with superior survival and improved perioperative outcomes following LVAD explant-OHT.
