Predicting survival beyond 5 years on continuous-flow left ventricular assist device: a landmark analysis from the...

Five-year survival after continuous-flow left ventricular assist device (LVAD) implantation has improved substantially, resulting in a growing population of ultra-long-term LVAD patients, defined as 5 years and longer survival on LVAD. Remarkably, determinants of mortality beyond the 5-year landmark remain poorly characterized, and ultra-long-term outcomes are rarely investigated.

We performed a large bicentre observational landmark analysis including patients who survived at least 5 years on LVAD support. Implanted devices included HeartMate II, HeartWare (HVAD), and HeartMate 3. Clinical, laboratory, echocardiographic, and haemodynamic parameters at the 5-year time point were evaluated to represent predictors of mortality. Cox proportional hazards regression was used to identify independent predictors of mortality from the 5-year landmark. Model discrimination was assessed using Harrell's C-index and time-dependent area under the curve.

Among 201 patients surviving ≥5 years on LVAD support, 189 had complete data for multivariable analysis. Median age at implantation was 59.9 years (IQR 52.6-65.8), and 86% were male. During post-landmark follow-up, 77 deaths occurred. Age (HR 1.04 per year, 95% CI 1.02-1.07; P = .002), haemoglobin (HR 0.84 per mmol/l, 95% CI 0.73-0.97; P = .016), MELD-XI score (HR 1.10 per unit, 95% CI 1.06-1.14; P < .001), and implantable cardioverter-defibrillator presence (HR 1.60, 95% CI 1.00-2.54; P = .049) were independently associated with mortality beyond the 5-year landmark. The model showed acceptable discrimination (Harrell's C-index ∼0.74). LVAD model was not independently associated with post-landmark mortality (likelihood-ratio P = .63).

Among patients who have already survived 5 years on continuous-flow LVAD support, subsequent mortality was associated with routinely available markers of physiological and end-organ reserve. These findings characterize risk specifically in prevalent long-term LVAD recipients and warrant external validation.