Optimal BP After HeartMate 3 LVAD May Be Higher Than Previously Thought

BOSTON, MA—The best mean arterial pressure (MAP) range in the first several months after implantation of the HeartMate 3 left ventricular assist device (LVAD) appears to be 85 to 100 mm Hg, according to a pooled analysis of RCT data.

Patients in that range in the first 90 days after receiving the implant had the lowest risk of a primary composite endpoint of death, pump thrombosis, stroke, bleeding, renal dysfunction, and right heart failure, Nelson Wang, MD, PhD (Brigham and Women’s Hospital, Boston), reported here at THT 2026.

In addition, spending more time in that target MAP range was associated with lower risks of the composite outcome, all-cause mortality, and stroke.

“In recipients of the HeartMate 3 LVAD, the optimal early mean arterial pressure is 85 to 100 mm Hg, with 85 to 95 representing the ideal range,” Wang told meeting attendees, noting that this is higher than the target range of 75 to 90 mm Hg recommended for LVAD recipients by the International Society for Heart and Lung Transplantation.

Nancy Sweitzer, MD, PhD (WashU Medicine, St. Louis, MO), a panelist at the late-breaking clinical science session where Wang presented the results, told TCTMD that those guidelines are based on the experience with older devices like HeartMate II and HeartWare, which are no longer on the market.

Physicians have been wondering whether those data would apply to the HeartMate 3 (Abbott), “and I think we long suspected it didn’t because the HeartMate II data showed that increased blood pressure in particular was associated with increased risk of thromboembolic events and pump clotting, which we don’t see with the HeartMate 3,” Sweitzer said.

In that context, “this is a super important study,” she said. “We have a different device, and what we knew previously with the other device doesn’t apply. And that’s, I think, not surprising at all. We just needed the data.”

Identifying a Target MAP Range

The analysis included pooled individual-level data from two trials of HeartMate 3, a centrifugal-flow, fully magnetically levitated LVAD: MOMENTUM 3 and ARIES-HM3. There were 1,983 patients (mean age about 59 years; 79% men) who were implanted with the device and had at least three MAP measurements taken in the first 3 months.

Wang et al split the cohort into four groups depending on the time in the target MAP range of 85 to 100 mm Hg identified in this study: 0, 1-31%, 32-66%, and 66-100%. Patients who spent no time in the target range had lower pre-implant MAPs compared with the other groups, while those in the lower two quartiles were more likely to have an ischemic cause of heart failure and to have undergone prior CABG, PCI, or valve replacement or repair compared with those in the upper two quartiles.

Perhaps we don’t need to be as aggressive at lowering blood pressure in patients with blood pressures in that 90 to 95 mm Hg range, or even 95 to 100 mm Hg range. Nelson Wang

The primary composite endpoint occurred in 27.0%, with 20.2% having a bleed, 3.3% having a stroke, and 5.1% dying from any cause.

For every 1-standard deviation (SD) increase in the time in target range (which equates to an increase of 35%), there were lower risks of the composite endpoint (adjusted HR 0.90; 95% CI 0.83-0.99), all-cause mortality (adjusted HR 0.69; 95% CI 0.55-0.86), stroke (adjusted HR 0.68; 95% CI 0.52-0.90), and right heart failure (adjusted HR 0.69; 95% CI 0.53-0.90). Relationships with risks of renal dysfunction and bleeding were not significant.

When divided into quartiles, patients who spent at least 32% of their time in the target range had a lower risk of composite events compared with those spending none of their time in that range. Similar, but stronger, relationships were seen for all-cause mortality.

In a continuous fashion, the relationship between time spent in the target range and outcomes was stronger for the range of 85 to 100 mm Hg identified in this study than it was for the guideline-recommended target of 75 to 90 mm Hg. This suggests “that a higher mean arterial pressure range may be more optimal in terms of clinical outcomes in this cohort,” Wang said.

Remaining Questions

There are, however, some unresolved issues, including what happens over the longer term. During the panel discussion, Sweitzer noted that this study examined only the first 3 months after the device implant. “These patients are around a long time now and we’re seeing a lot of low-flow events in patients who’ve had the devices a long time when they get higher blood pressures in particular,” she said. “So it’d be super interesting to see if this profile changes over time.”

It’s also unclear whether patients with lower MAPs in the first 3 months after implantation were simply sicker than the rest of the cohort.

We have a different device, and what we knew previously with the other device doesn’t apply. Nancy Sweitzer

From the audience, David Majure, MD (Weill Cornell Medicine, New York, NY), said that “one of the important distinctions is the difference between controlling blood pressure versus the risk of people who have lower blood pressure. And I think that’s going to be the key thing for clinical management that we need to tease out. How much of this is just the risk of the person versus how we use therapies to improve outcomes?”

Wang said the answer to that question would have to come from a trial randomizing patients to two different blood pressure ranges.

“But my take-home message from this,” he said, “is that perhaps we don’t need to be as aggressive at lowering blood pressure in patients with blood pressures in that 90 to 95 mm Hg range, or even 95 to 100 mm Hg range, given that oscillations outside of that range portend worse prognosis.”

To TCTMD, Sweitzer said she thinks “these data are going to impact how we manage our VAD patients, at least until we have more data.”