Respiratory failure cuts survival after LVAD placement

Patients who suffer from respiratory failure before and after implantation of left ventricular access devices (LVADs) have worse survival, according to a recent study presented at the 2019 Scientific Sessions of the American Heart Association (AHA 2019).

“In this analysis of the INTERMACS* registry, we describe the incidence and clinical outcomes associated with preimplant intubation and postimplant respiratory failure in patients undergoing LVAD implantation,” said researchers.

Of the 16,362 patients (median age, 59 years; 21.1 percent female) who underwent LVAD implantation, 5.5 percent (n=906) were intubated 48 hours before device placement, while 6.1 percent (n=1,001) developed respiratory failure within a week of the procedure. [Circulation 2019;doi:10.1161/CIRCHEARTFAILURE.119.006369]

Patients who required preimplant intubation had a 1-year survival rate of 54.3 percent. This was lower than that in their counterparts who did not need the procedure (62.5 percent). Multivariable Cox proportional hazards regression analysis confirmed that risk of death was significantly greater in the intubation group (hazard ratio [HR], 1.20, 95 percent confidence intervals [CI], 1.03–1.41; p=0.021).

Intubation prior to LVAD placement likewise worsened the incidence of adverse events such as bleeding, arrhythmia, stroke, respiratory failure, renal dysfunction and nondevice-related infections (p<0.01) in the year following the procedure. The likelihood of need rehospitalization, on the other hand, was significantly lower (p=0.013).

Preimplant intubation also resulted in greater frailty 3 months after device placement (7.4 percent vs 4.6 percent; p<0.001) and significantly poorer quality of life (mean scores: 66.7 vs 61.5; p=0.01).

Postprocedural respiratory failure within 1 week yielded similar outcomes. Multivariable analysis found a significantly higher risk of death in these patients within the first year after device placement (HR, 2.54, 95 percent CI, 2.26–2.85; p<0.001).

Predictors of postimplant respiratory failure included having a history of cardiac surgery, chronic lung disease, atrial arrhythmia and chronic kidney disease, as well as major infections occurring during the index admission.

“Our study examines the clinical impact of respiratory failure both prior to and immediately after LVAD implantation,” said the researchers. However, they pointed out that there is poor representation of this population in the existing trials, primarily due to steep exclusion criteria, and that this has important ramifications in terms of management.

“Perhaps due to the paucity of data from clinical trials, currently available societal guidelines offer limited guidance on how to manage patients intubated at the time of implantation,” according to the researchers.

“In addition to identifying a particularly sick population that may need closer monitoring or follow-up, these results may be helpful in counseling families of patients who develop this early complication,” they added.

*Interagency Registry for Mechanically Assisted Circularly Support