Identifying Temporal Relationships Between In‐Hospital Adverse Events After Implantation of Durable Left Ventricular Assist Devices

BACKGROUND: This study evaluated the impact of adverse events (AEs) on the development of subsequent AEs after left ventricular assist device (LVAD) surgery. METHODS AND RESULTS: The INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) was used to identify primary durable LVADs implanted between 2006 and 2016. The temporal relationships between AEs occurring during the index hospitalization were evaluated using separate risk‐adjusted Cox proportional hazard models. LVADs were implanted in 18 763 patients. The strongest positive relationships were renal failure leading to hepatic dysfunction (hazard ratio [HR], 6.62; 95% CI, 5.12–8.54; P<0.001), respiratory failure leading to renal failure (HR, 5.51; 95% CI, 4.79–6.34; P<0.001), respiratory failure leading to hepatic dysfunction (HR, 4.36; 95% CI, 3.25–5.83; P<0.001), renal failure leading to respiratory failure (HR, 4.18; 95% CI, 3.76–4.64; P<0.001), and renal failure leading to right ventricular assist device implant (HR, 3.70; 95% CI, 2.31–5.90; P<0.001). Although bleeding, infection, and right ventricular assist device implant were each associated with several subsequent AEs, the magnitude of association was less substantial. The lowest 1‐year post‐LVAD survival was associated with the primary AEs of renal failure (68.1%) and respiratory failure (70.7%) (log‐rank P<0.001). CONCLUSIONS: Most in‐hospital AEs after LVAD implantation have a significant association with the development of subsequent AEs, with the most profound impact associated with primary renal or respiratory failure, which are also associated with the lowest 1‐year survival. Targeting the reduction of renal or respiratory failure as the primary AE after LVAD surgery would likely yield the greatest reductions in overall AE burden and subsequent mortality.