Blood-based versus crystalloid cardiopulmonary bypass priming in left ventricular assist device surgery: impact on end-organ function and survival

OBJECTIVES: Cardiopulmonary bypass (CPB) priming may influence hemodilution, bleeding and end-organ injury during HeartMate 3 (HM3) implantation, but evidence in contemporary left ventricular assist device (LVAD) surgery is limited. METHODS: We retrospectively analysed 92 HM3 implantations (2015-2025) by priming strategy (blood-based [FFP+RBC], n = 36; crystalloid, n = 56). Primary endpoint was postoperative right heart failure (RHF; INTERMACS). Multivariable regression and propensity score-based inverse probability of treatment weighting (IPTW) sensitivity analyses were performed. RESULTS: Baseline characteristics were balanced between groups, with comparable age (blood-based: 58 [49.5-66.0]; crystalloid: 62 [55.8-68.2]; p = 0,069) and female sex (blood-based: n = 3/36 [8.3%]; crystalloid: n = 8/56 [14,3%]; p = 0.518). RHF was lower with blood-based priming (blood-based: n = 3/36 [8.3%]; crystalloid: n = 17/56 [30.4%]; p = 0.012; adjusted OR 0.23 [95% CI 0.06-0.86]; p = 0.030). Dialysis was lower unadjusted (blood-based: n = 4/36 [11.1%]; crystalloid: n = 18/56 [32.1%]; p = 0,021), with a directionally lower adjusted estimate (OR 0.30 [95% CI 0.09-1.01]; p = 0.053). Delirium was lower with blood-based priming (blood-based: n = 3/36 [8.3%]; crystalloid: n = 16/56 [28.6%]; p = 0,019; adjusted OR 0.22 [95% CI 0.06-0.84]; p = 0.027). Survival did not differ significantly (log-rank p = 0.055; adjusted HR 0.59 [95% CI 0.27-1.32]; p = 0.201). IPTW analyses showed lower delirium (OR 0.23; [95% CI 0.06-0.84]) and attenuated RHF association (OR 0.35; [95% CI 0.10-1.23]). CONCLUSIONS: Blood-based CPB priming was associated with lower RHF and delirium, and directionally lower dialysis rates, after HM3 implantation. Survival estimates were not statistically significant. Findings require prospective validation.