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Sex Differences in LVAD Use and Outcomes
Study Questions:
Are there sex differences in the use of left ventricular assist devices (LVADs) and in outcomes of patients awaiting heart transplant with a contemporary device?
Methods:
A cohort comprised of patients with HeartWare HVAD, HeartMate II, or HeartMate 3 as a bridge to heart transplantation between 2008 and 2018 was created from the United Network for Organ Sharing (UNOS) data set and analyzed using propensity score matching to determine the impact of sex on LVAD use and outcomes. The primary study endpoint was freedom from death or delisting for worsening status while on device support, and secondary endpoints included complications requiring UNOS status upgrade and cardiac transplantation.
Results:
Women comprised 20.8% of the 13,305 patients identified in this cohort. When compared to men, women were more likely to have HVAD at listing (35.5% vs. 29.2%), were younger (50.8 ± 12.8 vs. 53.5 ± 11.7, p < 0.001), and were more likely to be nonwhite (55.6% vs. 65.5% white, p < 0.001). The rate of LVAD use at listing increased at a slower rate in women between 2008 and 2017, and in 2017, was 18.9% in women vs. 29.9% in men. Women were less likely to have an ischemic etiology for heart failure (21.8% vs. 41.9%), diabetes, tobacco use, and implantable cardioverter-defibrillators. After propensity matching, women had higher calculated panel reactive antibody (cPRA) than men (24.6% vs. 10%, p < 0.001). Women on LVAD support were significantly less likely to be transplanted than men in the propensity-matched cohort (62.3% vs. 76%, p < 0.001) and more likely to die on the waitlist or to be removed due to worsening status. Sex was a significant predictor of waitlist mortality (hazard ratio, 1.51; p < 0.001).
Conclusions:
In the current era, there is a sex disparity in the use of LVADs among patients listed for heart transplant. Even after matching, women with LVAD are less likely than men to be transplanted and are more likely to die or be removed from the waitlist due to clinical worsening.
Perspective:
Sex disparities in use and outcomes of advanced therapies persist even in the current era of VAD technology. Prospective studies are needed to evaluate decision making and use of advanced therapies.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support
Keywords: Defibrillators, Implantable, Diabetes Mellitus, Heart Failure, Heart Transplantation, Heart-Assist Devices, Outcome Assessment, Health Care, Sex Characteristics, Tobacco Use, Women
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