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Improved Outcomes of Orthotopic Heart Transplant following Left Ventricular Assist Device Explant at High-Volume Centers: A UNOS Database Analysis
Catherine L. McGeoch, Reshma Kodimerla, Clayton J. Rust, Supreet S. Randhawa, Ailin Tang, Muath A. Bishawi, Mani A. Daneshmand, Joshua L. Chan
Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, Georgia, United States
Background: Given the ongoing limitations in donor organ availability, left ventricular assist devices (LVADs) remain critical for bridging patients with end-stage heart failure to orthotopic heart transplantation (OHT). LVAD explant at the time of transplantation has been associated with higher post-transplant morbidity and mortality, and existing evidence supports a positive relationship between OHT center volume and patient survival. However, contemporary data on outcomes following LVAD explant-OHT and the influence of center-specific procedural volume on these outcomes are limited. This study aimed to characterize the modern-era outcomes after LVAD explant-OHT and to assess whether high-volume centers confer a survival advantage compared to low-volume centers.
Methods: A retrospective analysis of the United Network for Organ Sharing (UNOS) database identified adult patients (?18 years) who underwent LVAD explant-OHT from 2011 to 2024. Centers were stratified into high- and low-volume groups based on the total number of LVAD explant-OHT procedures performed during the study period. High-volume centers were defined as those in the upper 50% of national case volume, which correlated to performing ?50 cases. The primary endpoint was 1-year all-cause mortality. Secondary endpoints included post-transplant length of stay (LOS), graft failure, stroke, and need for dialysis. Univariate and multivariable regression analyses were used to identify independent predictors of mortality. Kaplan-Meier analysis was performed to compare survival between high- and low-volume centers.
Results: A total of 2,978 adult patients underwent LVAD explant-OHT at 135 centers, of which 16 were classified as high-volume. Pre-transplant demographics, as shown in Table 1, revealed that patients at high-volume centers were older (53.6 vs. 51.3 years, p<0.001), had higher BMI (29.3 vs. 28.9, p=0.03), elevated preoperative creatinine (1.34 vs. 1.28 mg/dL, p=0.02), and a higher prevalence of type II diabetes (31.1% vs. 27.5%, p=0.04). Despite these higher-risk features, high-volume centers demonstrated superior outcomes (Table 2), including improved 1-year survival (79.4% vs. 76.2%, p=0.04), reduced post-transplant LOS (23.8 vs. 26.3 days, p=0.03), lower incidence of graft failure (24.1% vs. 29.4%, p=0.001), shorter mean ischemic time (3.33 vs. 3.45 hours, p=0.012), and lower postoperative dialysis (12.5% vs. 16.0%, p<0.001) and stroke rates (3.7% vs. 4.2%, p=0.004). Kaplan Meier analysis (Figure 1) revealed significantly improved long-term survival at high-volume centers (p=0.014). In multivariate analysis (Table 3), low-volume center status (HR 1.23, 95% CI 1.07–1.42, p=0.004), age (HR 1.01, 95% CI 1.00-1.02, p=0.003), BMI (HR 1.02, 95% CI 1.00-1.03, p=0.013), pre-transplant creatinine (HR 1.14, 95% CI 1.07-1.22, p<0.001), diabetes (HR 1.31, 95% CI 1.12-1.53, p=0.001), and ischemic cardiomyopathy (HR 1.28, 95% CI 1.10-1.48, p=0.001) were significant predictors of mortality.
Conclusions: High-volume centers performing LVAD explant-OHT achieved superior short- and long-term outcomes compared to low-volume centers, including improved 1-year survival, shorter post-transplant LOS, and lower rates of graft failure, dialysis, and stroke. These findings underscore the importance of procedural volume on post-transplant outcomes and support further consideration of center-specific experience in managing this higher-risk population.
Table 1. Baseline Recipient Characteristics by LVAD Explant OHT Center Volume
Table 2. LVAD Explant-OHT Outcomes by Center Volume
Table 3. Multivariate Predictors of Mortality
Figure 1. Kaplan-Meier Survival Analysis
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