Reply to the Comment: Optimizing LVAD Outcomes: Lessons from a Single-Center Experience

I would like to thank the reviewers for reviewing this article and for their comments.[1] [2] Indeed, it is challenging to make clear inferences when more than one type of Left Ventricular Assist Device (LVAD) is being placed. However, in our institution, it was certainly the case that the vast majority of implants after 2017 (and even the second half of 2017) were heartmate 3, though there were some pump exchanges from heartmate 2 to heartmate 2.

Regarding postoperative respiratory failure, I believe this is a problem of definition, as it does not correspond to being on a ventilator 3 days postoperatively in 45% of cases, as may be surmised by a cursory understanding of respiratory failure. Indeed, patients were usually extubated on postoperative day (POD) number 1, and not the evening of surgery, though in some cases, it may have extended to day 2 or 3 (but infrequently). Being on oxygen for a prolonged time period, or on high flow nasal oxygen to permit use of inhaled epoprostenol, would have been significantly more common, and likely accounts for the 44% number. Indeed, in Kentucky, pulmonary problems and marginal PFTs were frequent, and thus, prolonged use of nasal oxygen was certainly common. However, unless the patient had significant blood loss, or was taken back for bleeding, or had preoperative renal insufficiency, and then postoperative oliguria that required diuretic therapy for volume removal, our prolonged use of the ventilator was uncommon. Unfortunately, R.S.R.M. do not have the numbers to explain what percentage was due to ventilator dependence postoperatively. But it may be important to note that our post-LVAD length of stay was at the national mean or a day below for much of the time period from 2018 to 2021, which would argue that the postoperative respiratory failure was not a significant factor that impacted hospital stay.

Similarly, the incidence of driveline infection is difficult to define in a meaningful way. There are many patients who have drainage from a driveline site, and it's often serous. Also, there are many who have some positive cultures from the site, or some redness, but they frequently respond to oral antibiotics, and there is little significance to them beyond that. Some patients have malodorous purulent drainage, who require intravenous antibiotics or admission for driveline tunnel debridement, and certainly, this is clinically quite important as it leads to readmission. But even more substantially, there is a small percentage who present with bacteremia associated with a driveline infection with the same organism, and these have the worst prognosis, as it is now considered a systemic problem rather than a localized wound problem. Thus, stratifying the wound infection severity is more important than simply stating that a 37% incidence occurred. Intermacs looks at the parameter “time to first infection,” and in that variable, our results are parallel to the national average, and indeed at the mean.

Similarly, when measuring the intermacs parameter “time to first neurologic event,” we compare favorably, as our curves since 2018 at least, overlap and do not fare worse than the national average. These points indicate that our results are not necessarily due to the index event, such as surgery, but due to parameters that are medical or patient-related.

Finally, we do have some increase in right heart failure, but R.S.R.M. think this is a result of patient selection. Patients with marginal renal function, elevated creatinine, and preoperative biventricular dysfunction can all be excluded from LVAD therapy if we desired to do so. However, we are at a quaternary referral institution, and sometimes LVAD therapy, even if accompanied by short-term right ventricle (RV) failure, offers them the only reasonable chance of being discharged alive from the hospital. Our current strategy (not available in the previous era) is to optimize such patients by placing a temporary LVAD (Impella 5.5) and optimizing their right heart function, and filling pressures prior to durable LVAD implant.

Thank you again for reviewing our paper, and we appreciate your time.

Publication History

Received: 22 September 2025

Accepted: 22 September 2025

Article published online:
13 February 2026

• References

• 1 Karem S, Malyala RSR, Saha S. Left ventricular assist device in the management of heart failure: a single-center experience. Int J Angiol 2025; 34 (03) 220-225
• 2 Feng X, Nie X, Xu C. Optimizing LVAD outcomes: lessons from a single-center experience. Int J Angiol 2025; (ahead of publication).