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Center volume linked to worse LVAD survival
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Center volume of left ventricular assist device implantation procedures was associated with patient survival, according to a study.
Compared with medium-volume centers, centers with very low or high volume had higher 90-day mortality rates, researchers reported.
“While several studies have identified preoperative risk factors for mortality after LVAD implant, the impact of center surgical experience on overall patient survival has not been thoroughly examined,” Jennifer A. Cowger, MD, MS, medical director of mechanical circulatory support in the division of cardiovascular medicine and advanced heart failure/transplant at the Henry Ford Hospital in Detroit, and colleagues wrote in the study background.
Cowger and colleagues used data from the Interagency Registry for Mechanically Assisted Circulatory Support, which included information on center volume for 7,416 participants undergoing LVAD implants.
Center volume was categorized as very low ( 10 implants per year; n = 617 patients), low (11 to 30 implants; n = 2,561), medium (31 to 50 implants; n = 2,458) and high (> 50 implants; n = 1,750).
Survival and volume
At 1 year, overall survival was associated with center volume: 71% for very low volume, 81% for low volume, 83% for medium volume and 79% for high volume (P = .003).
The 90-day mortality rate was higher in very low-volume centers (OR = 1.35; P = .04) and high-volume centers (OR = 1.28; P =.018) vs. medium-volume centers.
After adjustment, mortality was elevated for very low- (HR = 1.32; 95% CI, 1.11-1.56), low-(HR 1.07; 95% CI, 0.95-1.21) and high-volume centers (HR = 1.17; 95% CI, 1.03-1.3) vs. medium-volume centers.
“Center surgical experience has been shown to impact patient outcome for many cardiac and noncardiac surgeries,” the researchers wrote. “Using a large national database of LVAD patients, we show that patients undergoing LVAD implant at very low-volume centers ( 10 LVADs per year) have inferior outcome to those implanted at centers performing 30 to 50 LVADS a year. In addition, patients implanted at high-volume centers (> 50 LVADs per year) have similar operative mortality but worse long-term survival than patients implanted at lower-volume centers. These results highlight the need for development of national performance evaluations for LVAD centers and reconsiderations of current U.S. LVAD center implant minimums.”
Thresholds may be unjust
In an accompanying editorial, Randall C. Starling, MD, MPH, and Andrew Xanthopoulos, MD, PhD, of the Kaufman Center for Heart Failure at Cleveland Clinic, wrote: “Access to care is important and limiting centers purely based upon a volume threshold would be unjust. A low volume center with experienced personnel and careful judgment night achieve excellent results. We believe a volume threshold should serve as a guide but that demonstrated excellent outcomes should trump a volume threshold.” – by Cassie Homer
Disclosures: Cowger reports she receives funds from HeartWare and St. Jude/Abbott. Starling reports he received institutional funding from Abbott and Medtronic and is a member of the INTERMACS Finance Committee. Xanthopoulos reports no relevant financial disclosures. Please see study for all other authors’ relevant disclosures.
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