CT-based cannula position predicts neurological risk in patients with HeartMate 3 LVAD

Introduction: Despite the HeartMate 3 (HM3) improved hemocompatibility, adverse neurological events (ANE) remain a major concern, and limited data exists on the combined effect of inflow and outflow cannula positioning on ANE risk. Methods: This single-center study included 103 HM3 recipients who underwent contrast-enhanced cardiac CT between 2016 and 2024. We measured inflow angle, inflow depth, distance to the anterior wall, and outflow angle. Optimal cutoffs were identified using ROC analysis, with associations with ANE evaluated by Kaplan-Meier and Cox regression. Results: Among the 103 patients, 25 (24%) experienced ANE over a median follow-up of 3.1 years. The ANE group had significantly shallower inflow depth (13.0 vs. 16.7 mm; p = 0.011) and a shorter distance to the anterior wall (13.0 vs. 16.7 mm; p = 0.006), along with a non-significant trend toward a larger outflow angle (56.3° vs. 51.7°; p = 0.175) and a more inferior inflow angle (-3.3°; p = 0.294). In multivariable Cox regression, inflow angle ≤ -4.1° (HR 4.34; 95% CI: 1.42-13.23), inflow depth ≤ 14.5 mm (HR 5.03; 95% CI: 1.76-14.37), and outflow angle > 42.7° (HR 5.52; 95% CI: 1.19-25.72) were independently associated with ANE. A greater number of cannula-related anatomical risk factors was significantly associated with worse 5-year ANE-free survival (p = 0.0004). Conclusions: Shallower inflow depth, inflow angle closer to inferior wall, and larger outflow angle, are significantly associated with ANE in HM3 patients. Optimizing cannula orientation during implantation may help mitigate stroke risk in this population.