E. Aguayo1, L. Mukdad1, A. Mantha1, A. Iyengar1, R. Hernandez1, P. Benharash1 1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiac Surgery,Los Angeles, CA, USA
Introduction: Left ventricular assist devices (LVAD) have significantly expanded the range of options for stabilizing and treating end stage heart failure. As LVAD technology continues to improve, the morbidity and mortality for patients is expected to approach that of orthotopic heart transplantation (OHT). While others have examined outcomes of such individual heart replacement modalities in trials, large-scale comparisons between OHT and LVADs have not been performed thus far. The present study was performed to compare the perioperative outcomes and 30-day readmissions between LVAD implantation and OHT using a national cohort.
Methods: Patients who underwent either OHT or LVAD implantation from 2010 to 2014 in the National Readmission Database (NRD) were selected. The NRD is an all-payer inpatient database maintained by the Healthcare Cost and Utilization Project that estimates more than 35 million annual U.S. hospitalizations. Mortality, readmission, and GDP-adjusted cost were evaluated using hierarchical linear models adjusting for socioeconomics, demographics, and comorbidities.
Results: Of the 13,660 patients identified during the study period, 5,806 (43%) received OHT while 7,854 (57%) received LVADs. LVAD patients were on average older (56 vs. 52, P<0.001) and had less severe comorbidities based on the Elixhauser Index (5.7 vs. 6.6, P<0.001). LVAD was associated with shorter length of stay after adjustment (37.1 vs 36.0 days, IRR:0.95, P<0.001), higher adjusted in-hospital mortality (12.3% vs. 7.0%, OR= 2.01, P<0.001), higher adjusted costs ($220,052 vs. $184,625, P<0.001), and longer readmission (10.0 days vs. 6.9 days, IRR: 1.28, P<0.001) length of stay. All-cause readmission at 30 days (27.5% LVAD vs 24.4% OHT, OR=1.02, P=0.81) and cost of readmission ($28,653 LVAD vs. $22,105 OHT, P=0.73) were not significantly different between modalities.
Conclusion: In this nationwide analysis of patients who underwent cardiac replacement therapy from 2010 to 2014 patients receiving LVAD had similar rate and cost of 30-day readmission compared to those undergoing OHT. These results further support recent studies indicating improved outcomes and survival using LVAD implantation. However, the initial cost of implantation and in-hospital mortality remain significantly greater among LVAD recipients after adjusting for demographics, comorbidities, and hospital variation. Given the projected increases in LVAD utilization and limited transplant donor pool, further emphasis on LVAD cost containment and comparative effectiveness is essential to the viability of such therapy in the era of value-based healthcare delivery.