Post-LVAD cognitive trajectories and determinants of non-improvement in end-stage heart failure

Cognitive impairment is common in patients with end-stage heart failure and may adversely affect self-management, treatment adherence, and clinical outcomes after left ventricular assist device (LVAD) implantation. Although LVAD support can improve systemic and cerebral perfusion, postoperative cognitive trajectories remain heterogeneous, and the factors associated with failure to improve are not well defined, particularly in Asian populations. This study aimed to characterize changes in cognitive function after LVAD implantation and to identify clinical, laboratory, echocardiographic, and neuroimaging determinants of cognitive non-improvement.

This single-center retrospective cohort study included 56 patients who underwent LVAD implantation and completed the Montreal Cognitive Assessment (MoCA) before surgery and approximately 1 year after surgery. Demographic and clinical characteristics, laboratory parameters, including bilirubin, echocardiographic indices, including right ventricular fractional area change (RV FAC) and valvular status, and head computed tomography (CT) findings were analyzed. Changes in MoCA scores were assessed using a paired t-test. Univariable and multivariable logistic regression analyses were performed to identify factors associated with postoperative cognitive non-improvement.

Before LVAD implantation, 39 of 56 patients (69.6%) had a MoCA score <26, indicating a high prevalence of baseline cognitive impairment. Alcohol use was more frequent among patients with cognitive impairment. At approximately 1 year after implantation, 43 of 56 patients (76.8%) showed improved MoCA scores, and the overall MoCA score increased significantly from baseline (P<0.05). In univariable analysis, ischemic cardiomyopathy, lower RV FAC, higher bilirubin levels, incident ischemic lesions on head CT, and new-onset ≥mild aortic regurgitation were associated with cognitive non-improvement. In multivariable analysis, elevated bilirubin and new-onset ≥mild aortic regurgitation remained independently associated with cognitive non-improvement.

Most patients with end-stage heart failure experienced significant cognitive improvement within 1 year after LVAD implantation, whereas approximately one quarter did not. Elevated bilirubin and new-onset ≥mild aortic regurgitation may help identify patients at increased risk of limited cognitive recovery and may support closer postoperative surveillance and earlier targeted intervention.