Delineating Pathways to Death by Multisystem Organ Failure in Patients with a Left Ventricular Assist Device

Laura Seese, Faezeh Movahedi, James Antaki, Arman Kilic, Rema Padman, Yiye Zhang, Manreet Kanwar, Sarah Burki, Christopher Sciortino, Mary Keebler, Sameer Hirji, Robert Kormos
Annals of Thoracic Surgery 2020 July 30

BACKGROUND: This study delineates the sequences of adverse events (AE) preceding mortality attributed to multisystem organ failure (MSOF) in patients with a left ventricular assist device (LVAD).

METHODS: We analyzed 3,765 AEs following 554 LVAD implants recorded in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) data registry between 2006 and 2015 that resulted in MSOF death. Hierarchical clustering identified and visualized quantitatively unique clusters of patients with similar AE profiles. Markov modeling was used to illustrate the AE sequences that led to MSOF death within the clusters. Cox proportional hazard models determined the risk-adjusted, pre-implant predictors of MSOF.

RESULTS: We identified two distinct MSOF clusters based on their proportion of AE types and survival time. The early-death cluster (418 pts, 2,304 AEs) had a median survival of 1 month (interquartile range [IQR] 3, 6) while the late-death cluster (118 pts, 1,461 AEs) had a median survival of 11 months (IQR 6, 22). The predominant AE sequences in the early-death and late-death clusters were renal failure-to-respiratory failure-to-death (62%) and bleeding-to-infection-to-respiratory failure-to-death (45%), respectively. Significant risk-adjusted pre-implant predictors of MSOF included line sepsis (HR 3.0, 95% CI 1.1, 8.2), ECMO (HR 2.2, 95% CI 1.2, 3.9) and dialysis or ultrafiltration (HR 2.1, 95% CI 1.5, 3.0).

CONCLUSIONS: This analysis identified two AE clusters and the predominant sequences that result in MSOF-associated mortality. One cluster of patients develop MSOF after chronic bleeding and repeated infections but have prolonged survival while another group expire early following renal and respiratory complications.

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