Trends in the use of percutaneous ventricular assist devices: analysis of national inpatient sample data, 2007 through 2012

Abstract

Importance: Percutaneous ventricular assist devices (PVADs) provide robust hemodynamic support compared with intra-aortic balloon pumps (IABPs), but clinical use patterns are unknown.

Objective: To examine contemporary patterns in PVAD use in the United States and compare them with use of IABPs.

Design, setting, and participants: Retrospective study of adults older than 18 years who received a PVAD or IABP while hospitalized in the United States (2007-2012).

Main outcomes and measures: Temporal trends in utilization, patient and hospital characteristics, in-hospital mortality, and cost of PVAD use compared with IABP.

Results: During 2007 through 2012, utilization of PVADs increased 30-fold (4.6 per million discharges in 2007 to 138 per million discharges in 2012; P for trend < .001) while utilization of IABPs decreased from 1738 per million discharges in 2008 to 1608 per million discharges in 2012 (P for trend = .02). In 2007, an estimated 72 hospitals used PVADs, increasing to 477 in 2011 (P for trend < .001). The number of hospitals with an annual volume of 10 or more PVAD procedures per year increased from 0 in 2007 to 102 in 2011 (21.4% of PVAD-using hospitals; P for trend < .001). Among PVAD recipients, 67.3% had a diagnosis of cardiogenic shock or acute myocardial infarction (AMI). There was a temporal increase in the use of PVADs in older patients and patients with AMI, hypertension, diabetes mellitus, and chronic kidney disease (P for trend < .001 for all). Overall, mortality in PVAD recipients was 28.8%, and mean (SE) hospitalization cost was $85,580 ($4165); both were significantly higher in PVAD recipients with cardiogenic shock (mortality, 47.5%; mean [SE] cost, $113,695 [$6260]; P < .001 for both). The PVAD recipients were less likely than IABP recipients to have cardiogenic shock (34.3% vs 41.2%; P = .001), AMI (48.0% vs 68.6%; P < .001), and undergo coronary artery bypass graft surgery (6.2% vs 43.2%; P < .001), but more likely to undergo percutaneous coronary intervention (70.9% vs 40.4%; P < .001). In propensity-matched analysis, PVADs were associated with higher mortality compared with IABP (odds ratio, 1.23 [95% CI, 1.06-1.43]; P = .007).

Conclusions and relevance: There has been a substantial increase in the use of PVADs in recent years with an accompanying decrease in the use of IABPs. Given the high mortality, associated cost, and uncertain evidence for a clear benefit, randomized clinical trials are needed to determine whether use of PVADs leads to improved patient outcomes.

Figure 1. Calendar Year Trends in the Use of Percutaneous Ventricular Assist Devices (PVADs) and Intra-aortic Balloon Pumps (IABPs) in the United States, 2007 Through 2012

The figure shows estimated use of PVADs and IABPs per million discharges, and the error bars represent standard errors. A, Use of PVADs increased from 4.6 per million in 2007 to 138 per million in 2012 (P for trend < .001). In contrast, use of IABPs decreased from 1738 per million in 2008 to 1608 per million in 2012 (P for trend = .02). B, Use of PVADs increased in patients with cardiogenic shock, acute myocardial infarction (AMI) without cardiogenic shock, and percutaneous coronary intervention (PCI) without AMI or cardiogenic shock (P for trend < .001 for all). C, Use of IABPs decreased in patients with cardiogenic shock and AMI without cardiogenic shock but increased in patients who underwent PCI without cardiogenic shock or AMI (P for trend < .001 for all).

Figure 2. Standardized Differences Between Variables Before and After Propensity Matching for Intra-aortic Balloon Pumps vsPercutaneous Ventricular Assist Devices

Vertical dotted lines indicate the acceptable range of standardized difference after propensity score matching (0-10%). CABG indicates coronary artery bypass graft; COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention.