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Blood-Based Versus Crystalloid Cardiopulmonary Bypass Priming in Left Ventricular Assist Device Surgery: Impact on
Sophie Bonni1, Rashad Zayat1, Natasja W M Ramnath1
1Department of Cardiac Surgery, University Hospital RWTH Aachen, Aachen 52074, Germany.
Insights
Blood-based cardiopulmonary bypass priming reduced right heart failure and delirium in HeartMate 3 left ventricular assist device recipients. Further studies are needed to confirm these findings.
Area of Science:
- Cardiovascular Surgery
- Medical Devices
- Critical Care Medicine
Background:
- Cardiopulmonary bypass (CPB) priming strategies may impact outcomes in left ventricular assist device (LVAD) surgery.
- Evidence regarding CPB priming effects on hemodilution, bleeding, and end-organ injury in contemporary HeartMate 3 (HM3) LVAD implantations is limited.
Purpose of the Study:
- To evaluate the association between CPB priming strategy and postoperative outcomes following HM3 implantation.
- To compare blood-based (fresh frozen plasma + red blood cells) versus crystalloid priming in HM3 recipients.
Main Methods:
- Retrospective analysis of 92 HM3 implantations (2015-2025).
- Patients were stratified by CPB priming strategy: blood-based (n=36) versus crystalloid (n=56).
- Primary endpoint was postoperative right heart failure (RHF); multivariable regression and inverse probability of treatment weighting (IPTW) were used for analysis.
Main Results:
- Blood-based priming was associated with significantly lower rates of RHF (8.3% vs 30.4%, p=0.012) and delirium (8.3% vs 28.6%, p=0.019).
- Unadjusted dialysis rates were lower with blood-based priming (11.1% vs 32.1%, p=0.021), with a trend towards significance after adjustment.
- IPTW analyses confirmed reduced delirium and an attenuated association with RHF for blood-based priming.
Conclusions:
- Blood-based CPB priming demonstrated a significant association with reduced RHF and delirium after HM3 implantation.
- A trend towards lower dialysis rates was observed with blood-based priming.
- Prospective validation is recommended to confirm these findings and guide clinical practice.
Objectives:
Cardiopulmonary bypass (CPB) priming may influence haemodilution, bleeding, and end-organ injury during HeartMate 3 (HM3) implantation, but evidence in contemporary left ventricular assist device (LVAD) surgery is limited.
Methods:
We retrospectively analysed 92 HM3 implantations (2015-2025) by priming strategy (blood-based [FFP + RBC], n = 36; crystalloid, n = 56). The primary end-point was postoperative right heart failure (RHF; Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS]). Multivariable regression and propensity score-based inverse probability of treatment weighting (IPTW) sensitivity analyses were performed.
Results:
Baseline characteristics were balanced between groups, with comparable age (blood-based: 58 [49.5-66.0]; crystalloid: 62 [55.8-68.2]; P = .069) and female sex (blood-based: n = 3/36 [8.3%]; crystalloid: n = 8/56 [14.3%]; P = .518). Right heart failure was lower with blood-based priming (blood-based: n = 3/36 [8.3%]; crystalloid: n = 17/56 [30.4%]; P = .012; adjusted OR 0.23 [95% confidence interval (CI) 0.06-0.86]; P = .030). Dialysis was lower unadjusted (blood-based: n = 4/36 [11.1%]; crystalloid: n = 18/56 [32.1%]; P = .021), with a directionally lower adjusted estimate (OR 0.30 [95% CI, 0.09-1.01]; P = .053). Delirium was lower with blood-based priming (blood-based: n = 3/36 [8.3%]; crystalloid: n = 16/56 [28.6%]; P = .019; adjusted OR 0.22 [95% CI, 0.06-0.84]; P = .027). Survival did not differ significantly (log-rank P = .055; adjusted HR 0.59 [95% CI, 0.27-1.32]; P = .201). IPTW analyses showed lower delirium (OR 0.23 [95% CI, 0.06-0.84]) and an attenuated RHF association (OR 0.35 [95% CI, 0.10-1.23]).
Conclusions:
Blood-based CPB priming was associated with lower RHF and delirium, and directionally lower dialysis rates, after HM3 implantation. Survival estimates were not statistically significant. Findings require prospective validation.
Clinical Registration Number:
Ethics Committee of the Medical Faculty of RWTH Aachen (EK 25-154).
