Impact of Center Left Ventricular Assist Device Volume on Outcomes After Implantation: An INTERMACS Analysis

Jennifer A. Cowger, John M. Stulak, Palak Shah, Todd F. Dardas, Francis D. Pagani, Shannon M. Dunlay, Simon Maltais, Keith D. Aaronson, Ramesh Singh, Nahush A. Mokadam, James K. Kirklin, Christopher T. Salerno

Research output: Contribution to journalArticlepeer-review

32 Scopus citations

Abstract

Objectives This study examined patient outcomes after left ventricular assist device (LVAD) implantation across a range of center surgical volumes. Background In order for a center to qualify for reimbursement, Centers for Medicare and Medicaid Services (CMS) requires it to implant ≥10 LVADs or total artificial hearts over a 3-year period. The impact of center LVAD surgical volumes on patient outcomes has not been thoroughly scrutinized. Methods Center volumes were provided for 7,416 patients undergoing LVAD implantation who were enrolled in INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support). Center LVAD volume was categorized as either very low (≤10 implants/year, n = 617), low (11 to 30 implants/year, n = 2,561), medium (31 to 50 implants/year, n = 2,458), or high (>50 implants/year, n = 1,750). The main outcome of interest was patient survival based on center volume derived from Kaplan-Meier and multivariate Cox regression. Results Overall survival was associated with center volume (p = 0.003), as follows: 71 ± 1.8% (very low volume), 81 ± 0.8% (low volume), 83 ± 0.8% (medium volume), and 79 ± 1.0% (high volume) at 1 year. Compared with medium volume centers, the 90-day mortality was higher in very low volume (odds ratio [OR]: 1.35; p = 0.04) and high volume (OR: 1.28; p = 0.018) VAD centers. The adjusted hazard ratios (HRs) for mortality were 1.32 (95% confidence interval [CI]: 1.11 to 1.56), 1.07 (95% CI: 0.95 to 1.21), and 1.17 (95% CI: 1.03 to 1.30) for very low, low, and high volume centers, respectively. Center volume did not predict mortality (p = 0.25; n = 3,688) in INTERMACS profile 1 patients (patients who had sustained cardiogenic shock) and profile 2 patients (patients with progressive hemodynamic decline despite inotropes). Conclusions Center volume correlates with post-VAD survival, with worse survival noted at very-low volume centers. These findings suggest that current U.S. VAD center standards warrant reconsideration.

Original languageEnglish (US)
Pages (from-to)691-699
Number of pages9
JournalJACC: Heart Failure
Volume5
Issue number10
DOIs
StatePublished - Oct 2017

Keywords

  • LVAD
  • mortality
  • risks
  • volume

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

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