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Predictors of 5-Year Mortality in Patients Managed With HeartMate 3 LVAD
Quick Takes
- Predictors for higher 5-year mortality risk in HeartMate 3 recipients discharged home alive included pre-implant factors (BUN >30 mg/dL and prior cardiothoracic surgery) and post-implant factors (hospitalization for stroke, bleeding, device thrombosis, ventricular arrhythmias, and eGFR<60 mL/min/1.73 m2).
- Five-year mortality risk was higher for patients with only post-implant risk factors or for those with both pre- and post-implant risk factors.
- Patient age was not a predictor for 5-year mortality risk.
Study Questions:
What clinical predictors are associated with 5-year mortality among HeartMate 3 (HM3, Abbott) left ventricular assist device (LVAD) recipients discharged alive post-implant?
Methods:
The authors used data from MOMENTUM 3, which was a randomized trial comparing HM3 LVAD to HeartMate II LVAD in advanced heart failure (HF) patients refractory to medical therapy. A total of 485 patients receiving HM3 who were discharged alive were included. The primary outcome of interest included all-cause mortality.
Results:
Overall, 38% HM3 recipients died in 5 years. Independent predictors identified for 5-year all-cause mortality among HM3 recipients discharged alive included: 1) elevated pre-implant blood urea nitrogen (BUN) >30 mg/dL, 2) prior cardiothoracic surgery for valve/coronary artery bypass grafting (CABG), 3) post-implant hospitalization for stroke/bleeding/device thrombosis, 4) post-implant hospitalization for ventricular arrhythmias, and 5) post-implant estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. For patients with no risk factors, 5-year mortality was 23%. For patients with only pre-implant risk factors (i.e., elevated pre-implant BUN and prior cardiothoracic surgery), 5-year mortality risk was similar to those without any risk factors. The mortality risk was highest for patients with only post-implant factors or a combination of pre- and post-implant factors. No predictors correlated with cause-specific death.
Conclusions:
Predictors of 5-year mortality in HM3 recipients included a combination of pre-implant (elevated BUN >30 mg/dL and prior cardiothoracic surgery) and post-implant factors (post-implant bleeding/stroke/device thrombosis, post-implant ventricular arrhythmias, and eGFR <60 mL/min/1.73 m2). The impact of pre-implant factors on mortality risk is modified by post-implant factors that lend a higher mortality risk.
Perspective:
HM3 is currently the only commercially available LVAD with randomized data demonstrating a 5-year all-cause mortality of 38% with this device. Using data from the HM3 randomized trial, the authors identify five risk factors that correlated with a higher mortality risk. Notably, this included a mix of pre- and post-implant factors but presence of only pre-implant factors did not correlate with a higher mortality risk; however, their impact was modified by presence of post-implant factors. This suggests that mortality risk in an individual who is higher risk due to pre-existing conditions can be modified by their post-implant course. Notably, age was not a predictor for 5-year mortality, suggesting that carefully selected older individuals may be reasonable candidates. Limitations of this study include smaller representation for non-White races and females in the trial, limiting its generalizability.
Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Mechanical Circulatory Support
Keywords: Arrhythmias, Cardiac, Blood Urea Nitrogen, Cardiac Surgical Procedures, Coronary Artery Bypass, Glomerular Filtration Rate, Heart-Assist Devices, Heart Failure, Patient Discharge, Risk, Secondary Prevention, Stroke, Thoracic Surgery, Thrombosis
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