Ultra-long-term outcomes after lvad support in older adults: insights from the STELLAR registry
C Velasquez-Silva, W H Nielsen, C H Moller, K Rossing, R Schramm, M Morshuis, S V Rojas, J F Gummert, F Gustafsson, H FoxAbstract
Background
The 2025 STS-INTERMACS Annual Report highlighted that durable LVAD therapy provides robust mid-term survival in older adults, with a substantial proportion of contemporary recipients aged >65 years and favorable five-year outcomes even among patients aged ≥70 years. These data underscore the expanding use of LVAD therapy across a broad age spectrum. However, available registry analyses primarily focus on outcomes up to five years after implantation. Whether survival trajectories beyond this landmark differ across age groups remains insufficiently explored.
Purpose
To investigate ultra-long-term survival beyond five years after LVAD implantation across age groups and to evaluate the impact of age at implant on subsequent mortality in the STELLAR registry.
Methods
STELLAR is a bicenter registry of patients supported with continuous-flow LVADs. Patients alive at five years after implantation were included; those without complete five-year follow-up were excluded. In a non–device-specific analysis, survival beyond the five-year landmark was assessed using Kaplan-Meier estimates and compared across age groups (<50, 50-65, ≥65 years at implant) using the log-rank test. Cox proportional hazards models were used to evaluate the association between age at implantation and subsequent mortality.
Results
A total of 200 patients who survived at least five years after LVAD implantation were included. Median follow-up beyond the five-year landmark was 384 days (IQR 181–954); (Table 1). During subsequent follow-up, 77 patients (38.5%) died, 30 (15%) underwent heart transplantation, 2 (1%) were explanted, and 91 (45.5%) remained on ongoing support. Survival beyond the five-year landmark differed significantly across age groups (log-rank P=0.00049). Among patients younger than 50 years at implantation, conditional survival at five years after the landmark exceeded 75%, whereas corresponding survival was 35.1% in patients aged 50–65 years and 22.0% in those aged ≥65 years. (Table 2). In Cox analysis, age at implantation was linearly associated with mortality beyond five years (HR 1.05 per year, 95% CI 1.02–1.07; P<0.001). Patients implanted before the age of 50 years had substantially lower ultra-long-term mortality (HR 0.20, 95% CI 0.08–0.49; P<0.001); (Graphic).
Conclusion
Although contemporary registry data demonstrate favorable five-year survival after LVAD implantation even in older patients, age at implant remains a major determinant of outcomes beyond this landmark. In the STELLAR registry, survival trajectories diverged markedly after five years, with sustained long-term benefit in younger recipients and progressively higher mortality with increasing age. These findings highlight that age-related risk becomes most apparent during ultra-long-term support and should be incorporated into age-specific counseling and long-term planning for patients considered for durable LVAD therapy.Graphic: Kaplan-Meier plot.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.