MSc Student University of Toronto Toronto, Ontario, Canada
Background: Durable left ventricular assist devices (LVADs) are increasingly used as destination therapy (DT) in advanced heart failure; however, there is a paucity of contemporary data reporting DT-LVAD outcomes in Canada. We therefore sought to characterize our 20-year experience at a high-volume Canadian centre.
METHODS AND RESULTS: All patients who received an LVAD with an initial DT indication from 2006–2025 were included. The primary outcome was major adverse cardiovascular events (MACE), defined as a composite of all-cause mortality, myocardial infarction, and right ventricular failure requiring right VAD support. The secondary outcome was a composite of hemocompatibility-related adverse events (HRAE), including pump thrombosis, stroke, and gastrointestinal bleeding. Time-to-event analyses were conducted for each outcome, and multivariate Cox regression identified risk factors for mortality. Data were censored at device exchange or heart transplantation. Fifty-eight patients were identified (HeartMate 3: 36 [62%]; HeartMate II: 10 [17%]; and HeartWare VAD: 12 [21%]). Median age was 67 years (IQR: 62–70), 21% were female, and 57% had ischemic cardiomyopathy. Median duration of LVAD support was 1.62 years (IQR: 0.19–4.11), with the longest-supported patient exceeding seven years (Figure 1). Patients were predominantly INTERMACS 4 (43%) and infrequently bridged with temporary devices (5%). Freedom from MACE was 81% at 30 days, 68% at 1 year, and 33% at 5 years post-implantation (Figure 2A). Freedom from HRAE was 71% at 30 days, 40% at 1 year, and 31% at 5 years (Figure 2B). No differences in overall MACE (p=0.82) or HRAE (p=0.23) were observed between devices; however, HeartMate 3 patients had the highest absolute survival rate (p < 0.01). During follow-up, there were 20 driveline infections, three device exchanges, and three heart transplants, all of which were bridged with a HeartMate 3. On multivariable analysis, age (HR, 1.20; 95% CI: 1.04–1.39; p=0.01), cardiopulmonary bypass time (HR, 1.01; 95% CI: 1.00–1.02; p< 0.01), and redo sternotomy (HR, 6.45; 95% CI: 1.94–21.45; p< 0.01) were independently associated with increased one-year mortality. A trend toward reduced mortality was also observed with the HeartMate 3 relative to the HeartMate II (HR, 0.33; 95% CI, 0.10–1.05; p=0.06).
Conclusion: To our knowledge, this is the first DT-LVAD cohort described in Canada. Although the HeartMate 3 has improved survival, the ongoing HRAE burden highlights the need for continued optimization of anticoagulation strategies. Operative characteristics may influence adverse event rates more than patient risk profiles. These findings support the feasibility and continued development of DT-LVAD programs in the Canadian context.
