Long-term trajectory and prognostic value of N-terminal pro-brain natriuretic peptide in patients with contemporary left ventricular assist device

Introduction There are scarce data if the dynamic changes of N-terminal pro-B-type natriuretic peptide (NT-proBNP) have predictive value for long-term outcomes in advanced heart failure (HF) patients supported by the contemporary left ventricular assist device (LVAD), HeartMate 3. Purpose This study aims to evaluate the long-term trajectory and prognostic value of NT-proBNP following the stabilization after HeartMate 3 LVAD implantation. Methods This single-center retrospective study included patients aged over 16 years who underwent HeartMate 3 LVAD implantation, with a follow-up duration of at least 90 days. All post-LVAD NT-proBNP measurements were retrieved and modeled using the linear mixed-effects model. Follow-up was censored at the time of transplantation or death. Survival analysis was performed using the log-rank test. A joint model was applied to evaluate the dynamic association between longitudinal NT-proBNP levels and mortality risk. Results From March 2016 to September 2025, a total of 188 patients underwent LVAD implantation at our center; among these, 16 (5.8%) died within 90 days, six had insufficient follow-up or lacked NT-proBNP measurements beyond 90 days. Consequently, 166 patients were analyzed and categorized into three groups according to NT-proBNP levels (normal <15 pmol/L) at 90 days after LVAD implantation, using tertiles (cut-off values: 143 and 261 pmol/L): low (n=57), intermediate (n=54), and high NT-proBNP group (n=55). The baseline characteristics were generally comparable across the three groups, except that the prevalence of chronic kidney disease was significantly increased across NT-proBNP tertiles (32%, 48%, and 56%, respectively, P=0.027). The hospital length of stay showed a stepwise increase across NT-proBNP tertiles (median [interquartile range]: 38 [28–58] days, 42 [32–61] days, and 53 [42–76] days, respectively; P=0.004). During the median follow-up of 2.4 (1.3–4.0) years, the high NT-proBNP group exhibited a significantly higher incidence of HF-related rehospitalization (53% vs. 26% and 41%, respectively; P=0.017) and significantly lower survival probability in the high NT-proBNP group compared with the other two groups (P=0.003, Figure). The average trajectory of NT-proBNP demonstrated relative stability after 90 days post-LVAD implantation. The joint model revealed that higher follow-up NT-proBNP levels were strongly associated with an increased instantaneous risk of mortality (hazard ratio [95% confidential interval]: 3.12 [1.95–4.84]; P<0.001). Conclusion Among advanced HF patients with contemporary HeartMate 3 LVAD, longitudinal changes in NT-proBNP discriminated distinct long-term trajectories and risk profiles. Higher NT-proBNP beyond 90 days was associated with more frequent long-term HF-related rehospitalization and worse survival. These findings support routine serial monitoring of NT-proBNP to enhance risk prediction and guide post-implant care in this population.