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Benefits of Neurohormonal Therapy in Patients With Continuous-Flow Left Ventricular Assist Devices

Yousefzai, Rayan MD*,†; Brambatti, Michela MD, MS; Tran, Hao A. MD; Pedersen, Rachel BA; Braun, Oscar Ö. MD, PhD,; Baykaner, Tina MD; Ghashghaei, Roxana MD; Sulemanjee, Nasir Z. MD; Cheema, Omar M. MD; Rappelt, Matthew BSc§; Baeza, Carmela BSc; Alkhayyat, Abdulaziz MD; Shi, Yang PhD§; Pretorius, Victor MD; Greenberg, Barry MD; Adler, Eric MD; Thohan, Vinay MD

doi: 10.1097/MAT.0000000000001022
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Left ventricular assist devices (LVADs) have dramatically improved short-term outcomes among patients with advanced heart failure. While neurohormonal blockade (NHB) is the cornerstone of treatment for patients with heart failure with reduced ejection fraction, its effect after LVAD placement has not been established. We reviewed medical records of 307 patients who underwent primary LVAD implantation from January 2006 to September 2015 at two institutions in the United States. Patients were followed for at least 2 years post-LVAD implantation or until explantation, heart transplantation, or death. Cox regression analysis stratifying on center was used to assess associations with mortality. Neurohormonal blockade use was treated as a time-dependent predictor. Stepwise selection indicated treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs) (hazard ratio [HR] = 0.53 [0.30–0.95], p = 0.03), age at the time of implantation (HR = 1.28 [1.05–1.56] per decade, p = 0.02), length of stay postimplantation (HR = 1.16 [1.11–1.21] per week, p < 0.01) and INTERMACS profile of 1 or 2 (HR = 1.86 [1.17–2.97], p < 0.01) were independent predictors of mortality. In this large, retrospective study, treatment with ACEIs or ARBs was an independent factor associated with decreased mortality post-LVAD placement.

From the *Lifespan Cardiovascular Institute, Rhode Island Hospital, Brown University, Providence, Rhode Island

Sulpizio Cardiovascular Center, University of California San Diego Health, La Jolla, California

Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Milwaukee, Wisconsin

§Center for Integrative Research on Cardiovascular Aging (CIRCA), Aurora Research Institute, Aurora Health Care, Milwaukee, Wisconsin. Dr. Shi is now with the National Institutes of Health, Rockville, Maryland.

Submitted for consideration July 2018; accepted for publication in revised form April 2019.

Disclosure: E.A. is a consultant for Medtronic.

M.B. received a personal award from the College of Physician and Surgeons of Ancona, Italy. O.Ö.B. was supported by the Swedish Heart-Lung Foundation, the Crafoords Foundation, Märta Winklers Stiftelse and Thorsten Westerströms Stiftelse, ALF Grants Region Skåne. V.T. received an intramural grant from the Aurora Research Institute (Milwaukee, WI) in support of this project.

Eric Adler and Vinay Thohan contributed equally to this work.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (www.asaiojournal.com).

Correspondence: Vinay Thohan, MD, Aurora Cardiovascular Services, Aurora St. Luke’s Medical Center, 2801 W. Kinnickinnic River Parkway, Milwaukee, WI 53215. Email: publishing112@aurora.org.

Copyright © 2019 by the American Society for Artificial Internal Organs