High-volume centers achieve superior outcomes in left ventricular assist device explant-heart transplantation

<h2>Abstract</h2><h3>Background</h3> Left ventricular assist device <b>(</b>LVAD) explantation at the time of orthotopic heart transplantation (OHT) carries increased perioperative risks. This study examined whether institutional operative volume influences outcomes following LVAD explant-OHT in a contemporary national cohort. <h3>Methods</h3> Adult patients who underwent LVAD explantation with OHT between 2011 and 2024 were identified in the Organ Procurement and Transportation Network/United Network for Organ Sharing registry. Using a rank-order method based on surgical volume, centers were stratified as either high volume or low volume. The primary outcome was 1-year survival; secondary outcomes included graft failure, ischemic time, dialysis, stroke, and hospital length of stay. Kaplan-Meier and Cox regression analyses were performed to assess survival and predictors of mortality. <h3>Results</h3> A total of 2863 patients across 121 centers were analyzed. Eight high-volume centers performed 31.3% (897 cases) of all LVAD explant-OHTs. Baseline characteristics, including heart failure etiology and LVAD device type, were similar in the 2 groups. High-volume centers demonstrated decreased ischemic time (mean, 3.1 ± 1.3 hours vs 3.5 ± 1.4 hours; <i>P</i> < .001), a lower rate of postoperative dialysis (12.7% vs 15.4%; <i>P</i> = .023), and shorter length of stay (mean, 22.8 ± 26.6 days vs 25.9 ± 31.3 days; <i>P</i> = .006) compared to low-volume centers. Graft failure was less common at high-volume centers (24.2% vs 28.8%; <i>P</i> = .011). One-year survival rate (81.6% vs 76.1%; <i>P</i> = .001) and median survival (4.93 years vs 4.00 years; <i>P</i> = .018) were greater at high-volume centers. Multivariable analysis identified low-volume center status as an independent predictor of higher mortality (hazard ratio, 1.28; 95% confidence interval, 1.10-1.50; <i>P</i> = .002). <h3>Conclusions</h3> High-volume centers were associated with superior survival and improved perioperative outcomes following LVAD explant-OHT.