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. Author manuscript; available in PMC: 2014 Jun 28.
Published in final edited form as: Am J Cardiol. 2013 Jul 25;112(9):1484–1488. doi: 10.1016/j.amjcard.2013.06.023

Relation of Preoperative Serum Albumin Levels to Survival in Patients Undergoing Left Ventricular Assist Device Implantation

Tomoko S Kato a,*, Shuichi Kitada a, Jonathan Yang b, Christina Wu a, Hiroo Takayama b, Yoshifumi Naka b, Maryjane Farr a, Donna M Mancini a, P Christian Schulze a
PMCID: PMC4074378  NIHMSID: NIHMS589170  PMID: 23891248

Abstract

Hypoalbuminemia has been recognized as a prognostic indicator in patients with heart failure. We aimed to investigate the association of hypoalbuminemia with postoperative mortality in patients undergoing left ventricular assist device (LVAD) implantation. We studied 272 consecutive patients undergoing LVAD implantation from 2000 to 2010 at our institution. Preoperative clinical characteristics and laboratory variables associated with mortality were analyzed. Postoperative survival of patients with preoperative hypoalbuminemia (<3.5 g/dl, n = 125) and those with normal albumin concentration (≥3.5 g/dl, n = 147) was compared. Survival after LVAD surgery was better in patients with normal albumin levels compared with those with hypoalbuminemia before surgery (3 and 12 months: 93.2% vs 82.4% and 88.4% vs 75.2%, respectively, p <0.001). Multivariate analysis revealed that preoperative albumin was independently associated with mortality after LVAD implantation (hazard ratio 0.521, 95% confidence interval 0.290 to 0.934; p = 0.029.) Furthermore, the impact of normalization of albumin levels during LVAD support on postoperative survival was analyzed in both groups. Subgroup analysis of patients with preoperative hypoalbuminemia and postoperative normalization of albumin levels (n = 81) showed improved survival compared with those who remained hypoalbuminemia (n = 44) or those who had decreasing albumin levels during LVAD support (n = 40; 3-month survival: 92.6% vs 63.6% and 65.0%; p <0.01). In conclusion, preoperative hypoalbuminemia is associated with poor prognosis after LVAD surgery. Postoperative normalization of albumin level is associated with improved survival. Attention to albumin levels by correcting nutrition, inflammation, and hepatic function could be an effective way to improve prognosis in patients evaluated for LVAD implantation.

Implantation of left ventricular assist devices (LVADs) as a bridge to heart transplantation and for destination therapy has demonstrated survival and quality-of-life benefits for patients with advanced heart failure.1–5 Postoperative outcome in patients undergoing LVAD implantation is associated with a number of preoperative factors including advanced age, malnutrition, renal or hepatic dysfunction, and right ventricular dysfunction.2,4,6–8 Although previous studies have identified abnormal liver and kidney functions and anemia to be associated with poor clinical outcome after LVAD surgery,4,9 no study has analyzed the specific role of albumin as an individual factor for post-LVAD prognosis. Serum albumin concentration is a marker of nutritional status, inflammation, hepatic synthetic function, and overall catabolic state.10–13 Hypoalbuminemia predicts poor outcome in patients with several chronic diseases including those with advanced heart failure.14,15 In addition, several reports have described the impact of preoperative hypoalbuminemia on postoperative short-term mortality after cardiac and noncardiac surgery.16–18 In the present study, we evaluated the specific impact of preoperative serum albumin levels on postoperative outcome after LVAD surgery. Furthermore, the impact of normalization of albumin levels during LVAD support on postoperative survival was investigated.

Methods

We retrospectively reviewed 272 consecutive patients with advanced heart failure undergoing elective implantation of a HeartMate I (n = 147) or a HeartMate II (n = 125) LVAD (both Thoratec Corp., Pleasanton, California) from November 2000 to August 2010 at the Columbia University Medical Center. Patients who underwent emergent LVAD implantation because of cardiogenic shock were excluded from the study. Preoperative clinical characteristics and laboratory examinations including serum albumin concentration were obtained from a clinical database. For patients with multiple laboratory measurements before the implantation, the results obtained at the date closest to the implantation were used for the present study.

We divided patients into 2 groups: those with preoperative hypoalbuminemia defined as albumin concentration <3.5 g/dl and those with normal albumin level (≥3.5 g/dl). Survival after LVAD implantation was compared between the groups. To determine the impact of hypoalbuminemia as a risk factor for mortality, we performed a multivariate analysis of the various preoperative factors including albumin levels associated with mortality.

Furthermore, we classified patients with and without preoperative hypoalbuminemia according to the dynamics in postoperative albumin levels to investigate the effect of changes in albumin levels during LVAD support on post-LVAD survival. Postoperative albumin levels were collected within 7 days from the end of observation or the device removal due to transplant, recovery, or death. Thus, subgroups of patients consisted of normal-to-normal (both pre- and postoperative normal albumin levels), normal-to-hypo (preoperative normal albumin level but postoperative hypoalbuminemia), hypo-to-normal (preoperative hypoalbuminemia but normalization of albumin postoperatively), and hypo-to-hypo (both pre- and postoperative hypoalbuminemia) groups. The study was approved by the Institutional Review Board of Columbia University Medical Center and all ethical guidelines outlined by the 1975 Declaration of Helsinki.

Data are presented as mean ± SD and frequency (percentage). Normality was evaluated for each variable on the basis of normal distribution plots and histograms and by the Kolmogorov-Smirnov test. Student unpaired t test was used to compare the variables between the groups. Categorical variables were compared using chi-square test. A Cox proportional hazard model was used to assess the impact of preoperative factors on postoperative mortality. Variables that achieved statistical significance in the univariate analysis were subsequently included in a multivariate analysis. Survival after LVAD implantation was compared using Kaplan-Meier methods with log-rank test. All statistical analyses were performed using SPSS 19.0 software (IBM, Armonk, New York).

Results

Among the entire cohort, 147 patients (54.0%) showed normal albumin concentration and 125 patients (46.0%) showed hypoalbuminemia (<3.5 g/dl). Clinical characteristics of patients with and without hypoalbuminemia are listed in Table 1.

Table 1.

Clinical characteristics of patients with and without hypoalbuminemia

Variable Serum Albumin
p
Normal, n = 147 (%) Low, n = 125 (%)
Age (yrs) 52.4 ± 15.0 55.5 ± 13.7 0.077
Men 115 (78.2) 102 (81.6) 0.648
Body mass index (kg/m2) 27.1 ± 5.5 25.5 ± 4.5 0.008
Coronary artery disease 117 (79.6) 107 (85.6) 0.206
Diabetes mellitus 48 (32.7) 36 (28.8) 0.513
Hyperlipidemia* 44 (29.9) 41 (32.8) 0.694
Hypertension 66 (44.9) 59 (47.2) 0.704
Peripheral vascular disease 24 (16.3) 16 (12.8) 0.493
Renal failure (chronic kidney disease stage ≥3) 52 (35.4) 35 (28.0) 0.240
Smoker 59 (40.1) 46 (36.8) 0.618
Preoperative laboratory value
 Albumin (g/dl) 3.9 ± 0.3 3.0 ± 0.3 <0.001
 White blood cell (×103/μl) 9.23 ± 3.80 10.52 ± 4.60 0.013
 Hematocrit (%) 35.0 ± 5.6 31.0 ± 5.6 <0.001
 Platelets (×103/μl) 193.3 ± 70.0 189.7 ± 102.0 0.737
 Total bilirubin (mg/dl) 1.6 ± 1.1 1.9 ± 1.4 0.055
 Sodium (mEq/L) 131 ± 9 131 ± 8 0.793
 Potassium (mEq/L) 4.2 ± 0.6 4.2 ± 0.6 0.683
 Blood urea nitrogen (mg/dl) 36.9 ± 19.2 34.6 ± 17.9 0.323
 Creatinine (mg/dl) 1.5 ± 0.6 1.5 ± 0.7 0.932
 Aspartate aminotransferase (IU/L) 108.0 ± 317.4 87.8 ± 193.0 0.535
 Alanine aminotransferase (IU/L) 91.2 ± 217.3 121.6 ± 311.8 0.348
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*

Hyperlipidemia was defined as a total cholesterol level of >239 mg/dl or a status requiring antihyperlipidemic medication.

Of the 147 patients with normal albumin levels before LVAD implantation, 107 patients (39.3% of total cohort) remained to have normal albumin levels postoperatively (normal-to-normal group), whereas 40 patients (14.7% of total cohort) developed hypoalbuminemia during LVAD support (normal-to-hypo group). Of patients with preoperative hypoalbuminemia, 81 patients (29.8% of total cohort) showed a normalization of albumin levels during LVAD support (hypo-to-normal group), whereas 44 patients (16.2% in total cohort) remained to have hypoalbuminemia postoperatively (hypo-to-hypo group).

Kaplan-Meier survival analysis revealed that patients with normal preoperative albumin levels showed better survival compared with that of patients with hypoalbuminemia during a mean observation period of 8.4 ± 10.2 months (survival at 3 and 12 months: 93.2% vs 82.4% and 88.4% vs 75.2%, respectively, p <0.001; Figure 1). After subdividing patients according to the device types, survival benefits of albumin levels were still seen in both patients who underwent HeartMate I and HeartMate II implantations (12-month survival, normal albumin level vs hypoalbuminemia; 96.1% vs 53.2% and 92.9% vs 78.9%, respectively; both p <0.001).

Figure 1.

Figure 1

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Kaplan-Meier survival curves of patients with and without preoperative hypoalbuminemia. Blue line indicates patients with normal albumin concentration defined as ≥3.5 g/dl and red line indicates patients with hypoalbuminemia (<3.5 g/dl). Dotted lines indicate 3- and 12-month mortalities of both groups.

Subanalysis of survival comparing patients classified according to dynamics in albumin levels during LVAD support is shown in Figure 2. Patients in the normal-to-normal group (3-month survival, 98.1%) showed better survival than any other subgroup (all p <0.001). Of note, patients with improvement of albumin levels from preoperative hypoalbuminemia showed better survival than that of normal-to-hypo and hypo-to-hypo groups (at 3 months: 92.6% vs 65.0% and 63.6%, respectively; both p <0.001). The post-LVAD survival of the normal-to-hypo group was not significantly different from the hypo-to-hypo group, indicating that levels of albumin had prognostic impact also in patients on LVAD support.

Figure 2.

Figure 2

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Kaplan-Meier survival curve of subgroup of patients classified by pre- and postoperative albumin levels. Blue line indicates hypo-to-hypo group, red line indicates normal-to-normal group, green line indicates normal-to-hypo group, and orange line indicates hypo-to-normal group. Survival at 3 months in normal-to-normal, normal-to-hypo, hypo-to-normal, and hypo-to-hypo groups was 98.1, 65.0, 92.6, and 63.6%, respectively.

Table 2 lists the preoperative factors associated with mortality after LVAD implantation. Variables found to be associated with mortality during LVAD support by univariate analyses were selected for inclusion into a subsequent multivariate analysis. Blood urea nitrogen and aspartate aminotransferase were selected for inclusion into the multivariate analysis but not creatinine or alanine aminotransferase because these variables were selected in a previous study for LVAD risk stratification.4 Multivariate analysis revealed that preoperative albumin levels were independently associated with postoperative mortality. The analysis revealed that with every 0.1 g/dl increase in albumin concentration, the postoperative mortality rate decreased by 4.8% adjusted for platelet count and aspartate aminotransferase.

Table 2.

Preoperative factors associated with postoperative mortality

Variable Univariate
Multivariate
HR (95% CI) p HR (95% CI) p
Age (yrs) 1.034 (1.010–1.059) 0.006 1.026 (0.999–1.053) 0.058
Men 1.023 (0.488–2.142) 0.952
Body mass index (kg/m2) 1.006 (0.951–1.065) 0.828
Coronary artery disease 1.151 (0.121–2.543) 0.729
Diabetes mellitus 1.077 (0.573–2.024) 0.819
Hyperlipidemia* 1.167 (0.625–2.179) 0.628
Hypertension 0.385 (0.131–1.130) 0.082
Peripheral vascular disease 1.364 (0.738–2.519) 0.322
Renal failure (chronic kidney disease stage ≥3) 0.856 (0.465–1.577) 0.618
Albumin (g/dl) 0.462 (0.266–0.803) 0.006 0.521 (0.290–0.934) 0.029
White blood cell (×103/μl) 1.014 (0.947–1.085) 0.695
Hematocrit (%) 0.983 (0.935–1.033) 0.503
Platelets (×103/μl) 0.994 (0.990–0.998) 0.004 0.996 (0.992–1.000) 0.030
Total bilirubin (mg/dl) 1.126 (0.899–1.410) 0.301
Sodium (mEq/L) 0.971 (0.956–1.026) 0.598
Potassium (mEq/L) 1.017 (0.618–1.674) 0.947
Blood urea nitrogen (mg/dl) 1.019 (1.004–1.034) 0.014 1.014 (0.997–1.032) 0.100
Creatinine (mg/dl) 1.659 (1.082–2.546) 0.020
Aspartate aminotransferase (IU/L) 1.001 (1.000–1.002) 0.009 1.001 (1.000–1.002) 0.025
Alanine aminotransferase (IU/L) 1.001 (1.000–1.002) 0.006
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CI = confidence interval; HR = hazard ratio.

*

Hyperlipidemia was defined as a total cholesterol level of >239 mg/dl or a status requiring antihyperlipidemic medication.

Discussion

In the present study, we have demonstrated that preoperative hypoalbuminemia is an independent factor associated with postoperative mortality in patients undergoing LVAD implantation. Patients with preoperative hypoalbuminemia with subsequent normalization of albumin levels after LVAD support showed a remarkable improvement of prognosis compared with those who remained to have hypoalbuminemia during LVAD support. In contrast, patients with normal preoperative albumin levels but subsequent hypoalbuminemia after LVAD implantation had lower survival compared with that of patients with preoperative hypoalbuminemia but normalization of albumin levels during LVAD support. Patients with normal preoperative albumin levels but postoperative hypoalbuminemia showed equally poor prognosis as those with both pre- and postoperative hypoalbuminemia.

Albumin levels are affected by several factors including rate of synthesis, catabolic state, inflammation, and distribution in the intra- and extravascular body compartments.10,11,14 Hypoalbuminemia has been reported to be associated with poor prognosis in patients with chronic disease states.19–21 In patients with heart failure, the prevalence of hypoalbuminemia has been reported to be approximately 20% to 30%, and it has emerged as an independent risk factor for mortality.14,15,22,23 The association of preoperative hypoalbuminemia and postoperative mortality in patients who underwent cardiac surgery has also been reported.16,24 In previous investigations, we reported an association between hypoalbuminemia and poor outcome for LVAD recipients4,6; however, these studies were limited to patients undergoing pulsatile LVAD implantation. The present study, for the first time, focused on the impact of preoperative hypoalbuminemia on postoperative survival in patients undergoing LVAD implantation, including those who received surgery in the modern continuous-flow device era. Here, we first describe that a normalization of albumin levels during LVAD support in patients with preoperative hypoalbuminemia is associated with improved survival. Recently, we reported that post-transplant survival of patients who showed normalization of liver function during LVAD support was similar to that of transplant recipients without preexisting liver dysfunction.25 Further investigations will be required to elucidate the importance of serial measurements of albumin level and its clinical impact on post-transplant survival.

We speculated that preoperative hypoalbuminemia was related to direct causes of early postoperative death in patients undergoing LVAD implantation. Indeed, death in patients with preoperative hypoalbuminemia occurred most frequently during the early postoperative period in our present observation. Hypoalbuminemia has been linked to systemic inflammation, sepsis, and infection.12,26 Patients with preoperative hypoalbuminemia may present with a persistent proinflammatory state even after LVAD implantation, which might contribute to early postoperative death and also greater susceptibility toward infection. Indeed, in the present study, patients with preoperative hypoalbuminemia showed higher white blood cell counts at baseline than those of patients with normal albumin levels. This may indicate that patients with preoperative hypoalbuminemia were in a proinflammatory state. In addition, patients with preoperative hypoalbuminemia suffer from poor wound healing, which further increases the risk of infection.27 We could only obtain limited information about the causes of death; however, infections and multiorgan failure were leading causes of death <1 year after LVAD implantation. Furthermore, we speculated that patients with preoperative hypoalbuminemia may have more bleeding complications and require larger amounts of blood products perioperatively. In the era of continuous-flow LVADs, bleeding complications are major causes of morbidity and mortality,28,29 and the use of anticoagulation agents, preexisting hemostatic abnormalities, and acquired von Willebrand syndrome may contribute to bleeding in patients with continuous-flow LVADs.29 Upper gastrointestinal bleeding was a frequent serious bleeding complication during LVAD support,29 and hypoalbuminemia has been reported as a strong predictor of mortality in patients with upper gastrointestinal bleeding.30 Patients with hypoalbuminemia may be prone to coagulation abnormalities resulting in higher frequency of bleeding complications.

Although previous risk stratification models for LVAD recipients did not solely focus on albumin levels and rather included it as a cofactor, we believe that measurement of albumin levels is a simple and easily obtainable risk stratification method in the clinical setting. Albumin level is routinely obtained preoperatively, but it is not considered a “biomarker” although it has a distinct prognostic power for predicting the outcome of patients with advanced heart failure undergoing surgical interventions.

In the present study, other factors related to liver function and metabolism including platelet count and aspartate aminotransferase in addition to albumin were also found to be associated with mortality. Our analysis, however, revealed that hypoalbuminemia was independently associated with mortality when these factors were adjusted by other variables. We speculate that hypoalbuminemia reflects not only liver function but also a multifactorial derangement that includes inflammation, malnutrition, and volume status.

Our observation was based on a single-center retrospective analysis. One of the limitations of this study was the lack of hemodynamic data before and after LVAD surgery. Another limitation was that we could not classify patients according to the purpose of LVAD implantation such as bridge-to-transplant and destination therapies. Further studies, especially regarding the association between albumin levels and LVAD-related adverse events, would provide greater clinical detail and relevance whether modifying hypoalbuminemia could further improve postoperative outcomes.

Acknowledgments

This work was supported by grants from the National Heart, Lung, and Blood Institute (K23 HL095742-01, P30 HL101272-01, UL1 RR 024156, HL073029), Bethesda, Maryland and the Herbert and Florence Irving Scholar Award, New York, New York to Dr. Schulze.

Footnotes

Disclosures

The authors have no conflicts of interest to disclose.

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