Clinical strategies and outcomes in advanced heart failure patients older than 70 years of age receiving the HeartMate II left ventricular assist device: a community hospital experience

Comparative analysis of survival rate and quality of life in axial-flow pump left ventricular assist devices (LVADs)

BACKGROUND

The rising heart failure rates globally show the pressing demand for treatment progress, especially in Left Ventricular Assist Devices (LVADs). Axial-flow pump LVADs are gaining notice for their small size, few moving parts, and potential for miniaturization, providing a vital option for heart transplants during donor shortages.

OBJECTIVES

Despite several studies on LVADs, there is a notable lack of research specifically comparing axial-flow pumps with similar technology. This gap hinders the identification of the most optimal technology to guide development efforts and meet patient needs. This study aims to comprehensively compare the most commonly used axial-flow pumps and provide a detailed analysis focusing on survival rates and quality of life parameters.

METHODS

As a developer of axial-flow pumps (LVADs), our group conducted a systematic review of the current axial-flow pump LVADs. We analyzed studies comparing these devices, focusing on key metrics such as survival rates and quality of life.

RESULTS

The HeartMate 2 and Jarvik 2000 show superior survival rates (up to 86.9 % at 6 months, 96.3 % at 3 years) and (6-month survival 67 %-91 %) respectively, compared to the other axial flow pumps LVAD. The results underscore the importance of choosing the optimal device and informing the direction of future developments.

CONCLUSION

In this paper, we aim to inform future studies to enhance their effectiveness and advance the overall performance of these devices, ultimately benefiting patients and developers. This review furnishes evidence-based recommendations for the most appropriate axial-flow pumps based on survival rates and quality of life parameters.

Clinical burden and predictors of non-cardiovascular mortality and morbidity in advanced heart failure

BACKGROUND

The changing demographic of heart failure (HF) increases the exposure to non-cardiovascular (non-CV) events. We investigated the distribution of non-CV mortality/morbidity and the characteristics associated with higher risk of non-CV events in patients with advanced HF.

METHODS

Patients from the HELP-HF registry were stratified according to the number of 2018 HFA-ESC criteria for advanced HF. Endpoints were non-CV mortality and non-CV hospitalization. Competing risk analyses were performed assessing the association between HFA-ESC criteria and study outcomes and the additional predictors of non-CV endpoints.

RESULTS

One thousand one hundred and forty-nine patients were included (median age 77 years-IQR 69-83). At 6, 12, 18 and 22 months, cumulative incidence of CV vs non-CV mortality was 13% vs 5%, 17% vs 8%, 20% vs 12%, 23% vs 12%, and of CV vs non-CV hospitalization was 26% vs 11%, 38% vs 17%, 45% vs 20%, 50% vs 21%. HFA-ESC criteria were associated with increasing adjusted risk of CV death, whereas no association was observed for CV hospitalization, non-CV death and non-CV hospitalization. Predictors of non-CV death were age, chronic obstructive pulmonary disease, dementia, preserved ejection fraction, >1 HF hospitalization and hemoglobin.

CONCLUSIONS

Patients with advanced HF are exposed to high, even though not predominant, burden of non-CV outcomes. HFA-ESC criteria aid to stratify the risk of CV death, but are not associated with lower competing risk of non-CV outcomes. Alternative factors can be useful to define the patients with advanced HF at risk of non-CV events in order to better select patients for treatments specifically reducing CV risk.

Bridging the gap in the symptomatic heart failure patient journey: insights from the Italian scenario

BACKGROUND

The prognosis for heart failure (HF) patients remains poor, with a high mortality rate, and a marked reduction in quality of life (QOL) and functional status. This study aims to explore the ongoing needs of HF management and the epidemiology of patients followed by Italian HF clinics, with a specific focus on cardiac contractility modulation (CCM).

RESEARCH DESIGN AND METHODS

Data from patients admitted to 14 HF outpatients clinics over 4 weeks were collected and compared to the results of a survey open to physicians involved in HF management operating in Italian centers.

RESULTS

One hundred and five physicians took part in the survey. Despite 94% of patients receive a regular follow-up every 3-6 months, available therapies are considered insufficient in 30% of cases. Physicians reported a lack of treatment options for 23% of symptomatic patients with reduced ejection fraction (EF) and for 66% of those without reduced EF. Approximately 3% of HF population (two patients per month per HF clinic) meets the criteria for immediate CCM treatment, which is considered a useful option by 15% of survey respondents.

CONCLUSIONS

Despite this relatively small percentage, considering total HF population, CCM could potentially benefit numerous HF patients, particularly the elderly, by reducing hospitalizations, improving functional capacity and QOL.

How to select a patient for LVAD

Left ventricular assist device (LVAD) implantation leads to improvement in symptoms and survival in patients with advanced heart failure. An important factor in improving outcomes post-LVAD implantation is optimal preoperative patient selection and optimization. In this review, we highlight the latest on the evaluation of patients with advanced heart failure for LVAD candidacy, including discussion of patient selection, implantation timing, laboratory and other testing considerations, and the importance of psychosocial evaluation. Such thorough evaluation by multidisciplinary team can serve to improve the outcomes of a complex group of patients with advanced heart failure being evaluated for LVAD.

Elderly Patients With Higher Acuity Have Similar Left Ventricular Assist Device Outcomes as Younger Patients at a Nontransplant Center

Although left ventricular assist device (LVAD) implantation is associated with acceptable survival, previous reports have demonstrated that advanced age is associated with increased short-term mortality. Because age is a relative contraindication to transplantation, nontransplant centers tend to implant a disproportionate number of elderly patients. We undertook this study to evaluate the impact of advanced age on LVAD outcomes at a nontransplant center. We conducted a retrospective review of all LVAD implants at our center from 2017 to 2022. Primary stratification was by age >70 years. The primary outcome was survival as assessed by the Kaplan-Meier method. The risk of 1-year mortality was further evaluated using multivariable Cox proportional hazards regression modeling. From 2017 to 2022, 93 patients underwent LVAD implantation. The mean age was 65.03 ± 11.28 years, with a median age of 68 (60 to 73) years. Most patients were INTERMACS 1 or 2 (71 patients; 76.34%). When stratified by age, 41 patients (44.09%) were aged ≥70 years. Patients aged ≥70 years had similar 30-day (96.15% vs 100.00%, p = 0.213), 1-year (90.05% vs 84.00%, p = 0.444), and 2-year survival (82.03% vs 84.00%, p = 0.870). When only the INTERMACS 1 and 2 patients with higher acuity were included, there was still no difference in 30-day, 1-year, or 2-year survival. On multivariable analysis, age >70 years was not associated with an increased hazard of 1-year mortality (0.90 [0.22 to 3.67], p = 0.878). In conclusion, in carefully selected patients, age >70 years is not associated with increased short-term mortality. Age alone should not be a contraindication to LVAD therapy.

How does age affect outcomes after left ventricular assist device implantation: results from the PCHF‐VAD registry

AIMS

Use of left ventricular assist devices (LVADs) in older patients has increased, and assessing outcomes in older LVAD recipients is important. Therefore, this study aimed to investigate associations between age and outcomes after continuous-flow LVAD (cf-LVAD) implantation.

METHODS AND RESULTS

Cf-LVAD patients from the multicentre European PCHF-VAD registry were included and categorized into those <50, 50-64, and ≥65 years old. The primary endpoint was all-cause mortality. Among secondary outcomes were heart failure (HF) hospitalizations, right ventricular (RV) failure, haemocompatibility score, bleeding events, non-fatal thromboembolic events, and device-related infections. Of 562 patients, 184 (32.7%) were <50, 305 (54.3%) were aged 50-64, whereas 73 (13.0%) were ≥65 years old. Median follow-up was 1.1 years. Patients in the oldest age group were significantly more often designated as destination therapy (DT) candidates (61%). A 10 year increase in age was associated with a significantly higher risk of mortality (hazard ratio [HR] 1.34, 95% confidence interval [CI] [1.15-1.57]), intracranial bleeding (HR 1.49, 95% CI [1.10-2.02]), and non-intracranial bleeding (HR 1.30, 95% CI [1.09-1.56]), which was confirmed by a higher mean haemocompatibility score (1.37 vs. 0.77, oldest vs. youngest groups, respectively, P = 0.033). Older patients suffered from less device-related infections requiring systemic antibiotics. No age-related differences were observed in HF-related hospitalizations, ventricular arrhythmias, pump thrombosis, non-fatal thromboembolic events, or RV failure.

CONCLUSIONS

In the PCHF-VAD registry, higher age was associated with increased risk of mortality, and especially with increased risk of major bleeding, which is particularly relevant for the DT population. The risks of HF hospitalizations, pump thrombosis, ventricular arrhythmia, or RV failure were comparable. Strikingly, older patients had less device-related infections.

Selection and management considerations to enhance outcomes in patients supported by left ventricular assist devices

PURPOSE OF REVIEW

Left ventricular assist devices (LVADs) are life-saving therapies for patients in end-stage heart failure (HF) with reduced ejection fraction regardless of candidacy for heart transplantation. Multiple clinical trials have demonstrated improved morbidity and mortality with LVADs when compared to medical therapy alone. However, the uptake of LVADs as a therapeutic option in a larger section of end-stage HF patients remains limited, partly due to associated adverse events and re-hospitalization.

RECENT FINDINGS

Accurate assessment and staging of HF patients is crucial to guide appropriate use of LVADs. Innovative methods to risk stratify patients and manage cardiac and noncardiac comorbidities can translate to improved outcomes in LVAD recipients. Inclusion of quality of life metrics and measurements of adverse events can better inform heart failure cardiologists to help identify ideal LVAD candidates. Addition of machine learning algorithms to this process may guide patient selection to improve outcomes.

SUMMARY

Patient selection and assessment of reversible medical comorbidities are critical to the postoperative success of LVAD implantation. Identifying patients most likely to benefit and least likely to experience adverse events should be a priority.

Heart Failure in Older Adults: Medical Management and Advanced Therapies

As the population ages and the prevalence of heart failure increases, cardiologists and geriatricians can expect to see more elderly patients with heart failure in their everyday practice. With the advancement of medical care and technology, the options for heart failure management have expanded, though current guidelines are based on studies of younger populations, and the evidence in older populations is not as robust. Pharmacologic therapy remains the cornerstone of heart failure management and has improved long-term mortality. Prevention of sudden cardiac death with implantable devices is being more readily utilized in older patients. Advanced therapies have provided more options for end-stage heart failure, though its use is still limited in older patients. In this review, we discuss the current guidelines for medical management of heart failure in older adults, as well as the expanding literature on advanced therapies, such as heart transplantation in older patients with end-stage heart failure. We also discuss the importance of a multidisciplinary care approach including consideration of non-medical co-morbidities such as frailty and cognitive decline.

Cardiac Surgery in Advanced Heart Failure

Mechanical circulatory support and heart transplantation are established surgical options for treatment of advanced heart failure. Since the prevalence of advanced heart failure is progressively increasing, there is a clear need to treat more patients with mechanical circulatory support and to increase the number of heart transplantations. This narrative review summarizes recent progress in surgical treatment options of advanced heart failure and proposes an algorithm for treatment of the advanced heart failure patient at >65 years of age.

Posttransplant Long-Term Outcomes for Patients with Ventricular Assist Devices on the Heart Transplant Waitlist

Ventricular assist devices (LVADs) are commonly used in end-stage heart failure for mechanical circulatory support as a bridge to heart transplantation. However, LVADs' long-term effects on posttransplant survival are unknown. We sought to compare long-term mortality after transplantation for patients with and without LVADs. Using the Organ Procurement and Transplantation Network database, we investigated LVADs' impact on long-term (3 month, 1 year, 2 years, 5 years, and 8 years) posttransplant mortality risk for all heart transplant recipients between 2010 and 2019. Time-to-event regression analysis quantified mortality risk by LVAD status in both unconditional and conditional survival analyses. Of 20,113 transplant recipients, 8,999 (45%) had a LVAD while on the waitlist. Among those who died after transplantation, patients with LVADs on average died sooner (1.8 years) than patients without LVADs (3.0 years; p < 0.01). On multivariable analysis, patients with LVADs had a 44% higher mortality risk within the first 3 months posttransplant (HR = 1.44, p = 0.03). There was no significant difference in mortality risk between patients who did and did not have pretransplant LVADs after 1, 2, and 5 years of posttransplant conditional survival. While LVAD patients have a survival disadvantage in the first year posttransplant, conditional survival analysis demonstrated no difference in mortality risk between patients with and without LVADs beyond 1 year of follow up. Of the patients who died posttransplant, patients with LVADs on average died sooner than patients without LVADs.

Socioeconomic Disparities in Referral for Invasive Hemodynamic Evaluation for Advanced Heart Failure: A Nationwide Cohort Study

BACKGROUND

Factors determining referral for advanced heart failure (HF) evaluation are poorly studied. We studied the influence of socioeconomic aspects on the referral process in Denmark, which has a taxpayer-funded national health care system.

METHODS

We identified all patients aged 18 to 75 years with a first diagnosis of HF during 2010 to 2018. Hospitalized patients had to be discharged alive and were then followed for the outcome of undergoing a right heart catheterization (RHC) used as a surrogate marker of advanced HF work-up.

RESULTS

Of 36 637 newly diagnosed patients with HF, 680 (1.9%) underwent RHC during the follow-up period (median time to RHC of 280 days [interquartile range, 73-914]). Factors associated with a higher likelihood of RHC included the highest versus lowest household income quartile (HR, 1.56 [95% CI, 1.19-2.06]; P=0.001), being diagnosed with HF at a tertiary versus nontertiary hospital (HR, 1.68 [95% CI, 1.37-2.05]; P<0.001) and during a hospitalization versus outpatient visit (HR, 1.67 [95% CI, 1.42-1.95]; P<0.001). Level of education, occupational status, and distance to tertiary hospital were not independently associated with RHC. Older age, cancer, and a psychiatric diagnosis were independently associated with a decreased probability of RHC.

CONCLUSIONS

Higher household income, HF diagnosis during hospitalization, and first admission at a tertiary hospital were associated with increased likelihood of subsequent referral for RHC independent of other demographic and clinical variables. Greater attention may be required to ensure timely referral for advanced HF therapies in lower income groups.

A mortality risk score for septuagenarians undergoing orthotopic heart transplantation

BACKGROUND

With septuagenarians undergoing orthotopic heart transplantation (OHT) more frequently, we aimed to develop a risk score for 1-year mortality in this population.

METHODS

Septuagenarian OHT recipients were identified from the UNOS registry between 1987 and 2018. The primary outcome was 1-year post-OHT mortality. Patients were randomly divided into derivation and validation cohorts. Associated covariates were entered into a multivariable logistic regression model. A risk score was created using the magnitudes of the odds ratios from the derivation cohort, and its 1-year post-OHT mortality prediction capacity was tested in the validation cohort.

RESULTS

A total of 1156 septuagenarians were included, and they were randomly divided into derivation (66.7%, n = 771) and validation (33.3%, n = 385) cohorts. An 11-point risk score incorporating 4 variables was created, which included mechanical ventilation, serum bilirubin, serum creatinine, and donor age. The predicted 1-year mortality ranged from 4.2% (0 points) to 48.1% (11-points) (p < .001). After cross-validation, the c-index was 0.67 with a Brier score of 0.10. Risk scores above 3 points portended a survival disadvantage at 1-year follow-up (p < .001).

CONCLUSIONS

This 11-point risk score for septuagenarians is predictive of mortality within 1-year of OHT and has potential utilization in improving recipient evaluation and selection of elderly patients.

An Analysis of Waitlist Inactivity Among Patients With Ventricular Assist Devices

BACKGROUND

Ventricular assist devices (VADs) are commonly used mechanical circulatory support for bridge to transplant therapy in end-stage heart failure; however, it is not understood how VADs influence incidence of waitlist inactive status. We sought to characterize and compare waitlist inactivity among patients with and without VADs.

METHODS

Using the Organ Procurement and Transplantation Network database, we investigated the VAD's impact on incidence and length of inactive periods for heart transplant candidates from 2005 through 2018. We compared median length of inactivity between patients with and without VADs and investigated inactivity risk with time-to-event regression models.

RESULTS

Among 46,441 heart transplant candidates, 32% (n = 14,636) had a VAD. Thirty-eight percent (n = 17,873) of all patients experienced inactivity, of which 42% (7538/17,873) had a VAD. Median inactivity length was 31 d for patients without VADs and 62 d for VAD patients (P < 0.0005). Multivariable analysis showed no significant difference in risk of inactivity for deteriorating conditions between patients with and without VADs after controlling for demographic and baseline clinical variables. A larger proportion of patients without VADs were inactive for deteriorating conditions than VAD patients (54%, n = 8242/15,221 versus 32%, n = 3583/11,086, P < 0.001). Ten percent (1155/11,086) of VAD patients' inactive periods were for VAD-related complications.

CONCLUSIONS

Although VAD patients were inactive longer and had an overall increased risk of any-cause inactivity, their risk of inactivity for deteriorating condition was not significantly different from patients without VADs. Furthermore, VAD patients had a smaller proportion of inactivity periods due to deteriorating conditions. Thus, VADs are protective from morbidity for waitlist patients.

Septuagenarian population has similar survival and outcomes to younger patients after left ventricular assist device implantation

BACKGROUND

Left ventricular assist device (LVAD) implantation may be an attractive alternative therapeutic option for elderly patients with heart failure who are ineligible for heart transplantation.

AIM

We aimed to describe the characteristics and outcomes of elderly patients (i.e. aged≥70 years) receiving an LVAD.

METHODS

This observational study was conducted in 19 centres between 2006 and 2016. Patients were divided into two groups-younger (aged<70 years) and elderly (aged≥70 years), based on age at time of LVAD implantation.

RESULTS

A total of 652 patients were included in the final analysis, and 74 patients (11.3%) were aged≥70 years at the time of LVAD implantation (maximal age 77.6 years). The proportion of elderly patients receiving an LVAD each year was constant, with a median of 10.6% (interquartile range 8.0-15.4%) per year, and all were implanted as destination therapy. Elderly and younger patients had similar durations of hospitalization in intensive care units and total lengths of hospital stays. Both age groups experienced similar rates of LVAD-related complications (i.e. stroke, bleeding, driveline infection and LVAD exchange), and the occurrence of LVAD complications did not impact survival in the elderly group compared with the younger group. Lastly, when compared with younger patients implanted as destination therapy, the elderly group also exhibited similar mid-term survival.

CONCLUSION

This work strongly suggests that selected elderly adults can be scheduled for LVAD implantation.

Comparison of Trends, Mortality, and Readmissions After Insertion of Left Ventricular Assist Devices in Patients <65 Years Vs ≥65 Years

Left ventricular assist devices (LVADs) use in treatment of stage D heart failure (HF) has evolved and expanded in the past decade. There is paucity of data on LVAD utilization in patients with age ≥65 years with multiple co-morbidities. We aimed to investigate utilization trends, outcomes, and rates and predictors of readmissions in patients receiving LVADs with age ≥65 years (AO) and comparing them with patient age <65 years (AY). We analyzed hospitalization data from the Nationwide Inpatient Sample from 2007 to 2015 to evaluate LVAD utilization trends and outcomes between the 2 patient cohorts. We also queried the Nationwide Readmission Database from 2014 to third quarter of 2015 to identify trends and compare etiologies of readmissions. Implants in AO patients increased from 20% (154) of the total LVADs implanted in 2007 to 33.2% (1,215) in 2014 and 31.8% (910) through September 2015 (p < 0.01). Over the study period there was a steady and significant increase in the mean Elixhauser scores in elderly patients who underwent LVAD implantation from 15.4 in 2007 to 24.54 in 2015 (p < 0.01). Despite this finding, the mean LOS in the AO cohort decreased from 56.0 days in 2007 to 33.8 days in 2015 (p < 0.001). Furthermore, the in-hospital mortality associated with LVAD implantation among the AO group gradually decreased over the study time period (39% in 2007 to 12.2% in 2015, p < 0.001). The overall readmission rate was not significantly different between AO versus AY group (28% vs 33%, p = 0.2). The most common cause in both groups was gastrointestinal bleed but it was significantly higher in AO group (24.3% vs 11.3%, p = 0.01). In conclusion, patients age ≥65 years with multiple co-morbidities are receiving increasing number of LVADs with improved survival outcomes. Their 30-day readmissions are comparable to the younger patients.

The Effect of Age on Outcomes After Destination-Therapy Left Ventricular Assist Device Implantation: An Analysis of the IMACS Registry

BACKGROUND

As patients with advanced heart failure are living longer, defining the impact of left ventricular assist devices (LVADs) on outcomes in an aging population is of great importance. We describe overall survival, rates of adverse events (AEs), and post-AE survival in patients age ≥ 70 years vs age 50-69 years after destination-therapy (DT) LVAD implantation.

METHODS

A retrospective analysis was conducted with the use of the International Society for Heart and Lung Transplantation Mechanically Assisted Circulatory Support (IMACS) registry. All adults age ≥ 50 years with a continuous-flow DT LVAD from 2013 to 2017 were included. The primary outcome was all-cause mortality. The secondary outcomes were the incidence of and survival after gastrointestinal (GI) bleeding, infection, stroke, pump thrombosis, pump exchange, and right-side heart failure. Mortality and AEs were assessed with the use of competing risk models.

RESULTS

At total of 5,572 patients were included: 3,700 aged 50-69 and 1,872 aged ≥ 70. All-cause mortality by 42 months was 55.8% in patients aged ≥ 70 and 44.8% in patients aged 50-69 (P = 0.001). Patients aged ≥ 70 had a 37.8% higher risk of death after DT LVAD implantation (hazard ratio 1.378, 95% CI 1.251-1.517). Patients aged ≥ 70 had higher risk of GI bleeding but lower risk of right-side heart failure. There was no difference between age groups for risk of infection or stroke. Experiencing any AE was associated with an increased risk of death that did not vary with age.

CONCLUSIONS

Patients aged ≥ 70 years have reduced survival after DT LVAD, in part because of increased GI bleeding, while the incidence of other AEs is similar to that of patients aged 50-69 years. Careful patient selection beyond age alone may allow for optimal outcomes after DT LVAD implantation.

Noncardiac surgery in patients with a left ventricular assist device

Left ventricular assist devices are implanted in patients with chronic left heart failure refractory to maximal medical therapy. These devices were initially meant as bridge-to-transplant therapy, but with technological advances they are now also used as destination therapy. With improved survival, many patients with implanted devices need noncardiac surgery. We present three representative cases of noncardiac surgery in such patients to highlight the issues involved in their management. We also review the contemporary literature on various aspects of perioperative management. Anesthesia for noncardiac surgery in these patients was initially the domain of cardiac anesthesiologists, but with an increasing number of such patients needing surgery, general anesthesiologists are frequently tasked to provide anesthetic care. An understanding of left ventricular assist device physiology and issues unique to these patients is essential for safe management of these cases.

2019 EACTS Expert Consensus on long-term mechanical circulatory support

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.

Mitral valve repair for severe mitral valve regurgitation during left ventricular assist device implantation

BACKGROUND

The management of severe mitral regurgitation (MR) at the time of left ventricular assist device (LVAD) implantation is controversial. We adopted an approach of systematic repair of severe MR at the time of LVAD implantation and report our experience.

METHODS

We performed mitral valve repair (MVr) on 78 consecutive patients with severe MR undergoing LVAD implantation at our institution between 2013 and 2017. We compared data on these patients to 28 historical controls with severe MR from the immediate preceding period between 2011 and 2013 where the MR was not treated, using Cox modeling and propensity score methods. Median follow-up time was 17.7 months.

RESULTS

Patients who underwent MVr were younger than those who did not (non-MVr group) (55 vs 63 years; P = .006), but otherwise had similar preoperative characteristics. The incidence of 30-day mortality (2.6% vs 3.6%; P = .78) and other early major adverse events was similar in both groups. At 3 months, no patient in the MVr group had more than mild MR compared with 7 patients (29%) in the non-MVr group (P < .001). Cardiac catheterization done 3 to 6 months after surgery showed tendency toward greater reduction from preoperative pulmonary artery systolic pressure in the MVr group compared with the non-MVr group (-20 vs -13 mm Hg; P = .10). The cumulative incidence of readmission due to congestive heart failure at 2 years was lower in the MVr group than in non-MVr group (7.1% vs 19.7%; adjusted hazard ratio, 0.18; 95% confidence interval, 0.04-0.76; P = .02).

CONCLUSIONS

Concurrent MVr at the time of LVAD implantation can be done safely without increase in perioperative adverse events. MVr may be associated with better reduction in severity of MR and may have potential benefit in terms of reduction in readmissions for heart failure.

Patient activation with respect to advanced heart failure therapy in patients over age 65 years

BACKGROUND

Clinical and ethical issues persist in determining candidacy for advanced heart failure (HF) therapies in elderly patients. Selection takes many factors into account, including "activation" (engagement and ability to self-manage).

OBJECTIVE

To investigate effects of age, activation, and depression/anxiety on selection and 6-month survival of participants considered for therapy.

METHODS

Consecutive people referred for advanced HF therapy completed the Patient Activation Measure and Hospital Anxiety and Depression Scale. We analyzed data from participants by age (≥65 vs. <65 years), stratified by approval for therapy.

RESULTS

Among 168 referred, 109 were approved, with no difference in activation between age groups (88% highly activated). Similarly, activation was not associated with age among those not approved. Activation was related to anxiety in older, approved participants, but not to depression.

CONCLUSIONS

Concerns regarding reduced self-management in the elderly may not be valid. Age alone should not disqualify a candidate for advanced HF therapy.

Reviewing the use of ventricular assist devices in the elderly: where do we stand today?

INTRODUCTION

Implantation of left ventricular assist devices (LVADS) in older patients appears to be an attractive option in the wake of donor shortage and increasing incidence and prevalence of end stage heart failure. Since the inception of the artificial heart program half a century ago tremendous progress in research and development has led to utilization of more sophisticated devices. VADs have therefore emerged as a successful therapy for extending life with meaningful quality. Areas covered: This review will address the use of LVADS as a bridge to transplantation, destination therapy and comparison of LVAD therapy with alternate list heart transplantation in the elderly population. Expert commentary: Age >70 years is an important aspect when assessing LVAD risk, but other characteristics appear to be better predictors of LVAD survival. Elevated pre-operative creatinine, bilirubin and ischemic etiology predispose to a higher risk of mortality. Creatinine has been shown to be a very powerful predictor in post LVAD survival. Based on the existing literature, the authors suggest an algorithm which could be useful when evaluating patients for LVAD implantation.

Impact of age, sex, therapeutic intent, race and severity of advanced heart failure on short-term principal outcomes in the MOMENTUM 3 trial

BACKGROUND

Primary outcomes analysis of the Multicenter Study of MagLev Technology in Patients Undergoing MCS Therapy With HeartMate 3 (MOMENTUM 3) trial short-term cohort demonstrated a higher survival rate free of debilitating stroke and reoperation to replace/remove the device (primary end-point) in patients receiving the HeartMate 3 (HM3) compared with the HeartMate (HMII). In this study we sought to evaluate the individual and interactive effects of pre-specified patient subgroups (age, sex, race, therapeutic intent [bridge to transplant/bridge to candidacy/destination therapy] and severity of illness) on primary end-point outcomes in MOMENTUM 3 patients implanted with HM3 and HMII devices.

METHODS

Cox proportional hazard models were used to analyze patients enrolled in the "as-treated cohort" (n = 289) of the MOMENTUM 3 trial to: (1) determine interaction of various subgroups on primary end-point outcomes; and (2) identify independent variables associated with primary end-point success.

RESULTS

Baseline characteristics were well balanced among HM3 (n = 151) and HMII (n = 138) cohorts. No significant interaction between the sub-groups on primary end-point outcomes was observed. Cox multivariable modeling identified age (≤65 years vs >65 years, hazard ratio 0.42 [95% confidence interval 0.22 to 0.78], p = 0.006]) and pump type (HM3 vs HMII, hazard ratio 0.53 [95% confidence interval 0.30 to 0.96], p = 0.034) to be independent predictors of primary outcomes success. After adjusting for age, no significant impact of sex, race, therapeutic intent and INTERMACS profiles on primary outcomes were observed.

CONCLUSIONS

This analysis of MOMENTUM 3 suggests that younger age (≤65 years) at implant and pump choice are associated with a greater likelihood of primary end-point success. These findings further suggest that characterization of therapeutic intent into discrete bridge-to-transplant and destination therapy categories offers no clear clinical advantage, and should ideally be abandoned.

Left Ventricular Assist Device in Older Adults

Left ventricular assist devices (LVADs) are an effective therapy for a growing and aging population in the background of limited donor supply. Selecting the proper patient involves assessment of indications, risk factors, scores for overall outcomes, assessment for right ventricular failure, and optimal timing of implantation. LVAD complications have a 5% to 10% perioperative mortality and complications of bleeding, thrombosis, stroke, infection, right ventricular failure, and device failure. As LVAD engineering technology evolves, so will the risk-prediction scores. Hence, more large-scale prospective data from multicenters will continually be required to aid in patient selection, reduce complications, and improve long-term outcomes.

Left Ventricular Assist Devices for Lifelong Support

Continuous-flow left ventricular assist devices (LVADs) have revolutionized advanced heart failure care. These compact, fully implantable heart pumps are capable of providing meaningful increases in survival, functional capacity, and quality of life. Implantation volumes continue to grow, but several challenges remain to be overcome before LVADs will be considered as the therapy of choice for all patients with advanced heart failure. They must be able to consistently extend survival for the long term (7 to 10 years), rather than the midterm (3 to 5 years) more typical of contemporary devices; they must incorporate design elements that reduce shear stress and avoid stasis to reduce the frequent adverse events of bleeding, stroke, and pump thrombosis; and they must become more cost-effective. The advancements in engineering, implantation technique, and medical management detailed in this review will highlight the progress made toward achieving lifelong LVAD support and the challenges that remain.

Frailty in Advanced Heart Failure

Frailty is defined as a biological syndrome reflecting impaired physiologic reserve and heightened vulnerability to stressors. The evolving profile of heart failure (HF), increased survival of aging patients with complex comorbidities in parallel with the growing population undergoing mechanical circulatory support as lifetime therapy, means that advanced HF specialists are becoming aware of the burden of frailty and its downstream consequences on postintervention outcomes in these patients. The limited data available to date suggest that frailty is highly prevalent in patients with advanced HF and appears to provide prognostic information not captured by traditional risk assessment.

Age and gender differences and factors related to change in health-related quality of life from before to 6 months after left ventricular assist device implantation: Findings from Interagency Registry for Mechanically Assisted Circulatory Support

BACKGROUND

Gaps in the literature exist regarding health-related quality of life (HRQOL) early after left ventricular assist device (LVAD) surgery. The purposes of our study were to describe HRQOL over time, by age and gender, and identify risk factors for poor HRQOL early after LVAD implant.

METHODS

Patients (n = 7,353) from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database received a continuous-flow LVAD as a primary implant at 133 United States hospitals. Of these, 5,640 patients had pre-LVAD HRQOL data, 3,353 patients had 6-month post-LVAD HRQOL data, and 2,748 patients had data at both times. HRQOL was measured using the EQ-5D-3L (Euro-Qol) instrument. Data were collected pre-implant and 3 and 6 months post-operatively. Statistical analyses included chi-square test, t-test, Pearson correlation coefficients, and multiple regression analysis.

RESULTS

Overall HRQOL and dimensions of HRQOL improved from before to 6 months after device implant when examined by age and gender. However, younger patients and women reported significantly more problems regarding all dimensions before implant and significantly more problems regarding pain/discomfort and anxiety/depression at 3 and 6 months after implant. An increase in overall HRQOL from before to 6 months after implant was related to pre-implant INTERMACS Level 1. Factors related to a decrease in HRQOL from before to 6 months after implant were listed for heart transplant before surgery, comorbidities, better preoperative HRQOL, adverse events within 6 months after implant, bridge to transplant moderately likely and unlikely, and New York Heart Association Functional Classification IV at 6 months after LVAD (R(2) = 41%).

CONCLUSIONS

Overall HRQOL and dimensions of HRQOL improve in sub-groups of patients from before to 6 months after surgery, although differences in improvement exist. Adverse events are risk factors for decreased HRQOL across time and support the ongoing need to improve device technology with the aim of reducing adverse events.

Durable left ventricular assist device therapy in advanced heart failure: Patient selection and clinical outcomes

The increasing adoption of left ventricular assist devices (LVADs) into clinical practice is related to a combination of engineering advances in pump technology and improvements in understanding the appropriate clinical use of these devices in the management of patients with advanced heart failure. This review intends to assist the clinician in identifying candidates for LVAD implantation, to examine long-term outcomes and provide an overview of the common complications related to use of these devices.

Short and long term outcomes of 200 patients supported by continuous-flow left ventricular assist devices

AIM: To study the institutional experience over 8 years with 200 continuous-flow (CF) - left ventricular assist devices (LVAD).

METHODS: We evaluated our institution’s LVAD database and analyzed all patients who received a CF LVAD as a bridge to transplant (BTT) or destination therapy from March 2006 until June 2014. We identified 200 patients, of which 179 were implanted with a HeartMate II device (Thoratec Corp., Pleasanton, CA) and 21 received a Heartware HVAD (HeartWare Inc., Framingham, MA).

RESULTS: The mean age of our LVAD recipients was 59.3 years (range 17-81), 76% (152/200) were males, and 49% were implanted for the indication of BTT. The survival rate for our LVAD patients at 30 d, 6 mo, 12 mo, 2 years, 3 years, and 4 years was 94%, 86%, 78%, 71%, 62% and 45% respectively. The mean duration of LVAD support was 581 d (range 2-2595 d). Gastrointestinal bleeding (was the most common adverse event (43/200, 21%), followed by right ventricular failure (38/200, 19%), stroke (31/200, 15%), re exploration for bleeding (31/200, 15%), ventilator dependent respiratory failure (19/200, 9%) and pneumonia (15/200, 7%). Our driveline infection rate was 7%. Pump thrombosis occurred in 6% of patients. Device exchanged was needed in 6% of patients. On multivariate analysis, preoperative liver dysfunction, ventilator dependent respiratory failure, tracheostomy and right ventricular failure requiring right ventricular assist device support were significant predictors of post LVAD survival.

CONCLUSION: Short and long term survival for patients on LVAD support are excellent, although outcomes still remain inferior compared to heart transplantation. The incidence of driveline infections, pump thrombosis and pump exchange have declined significantly in recent years.

Present-Day Hospital Readmissions after Left Ventricular Assist Device Implantation: A Large Single-Center Study

Left ventricular assist device (LVAD) therapy improves survival, hemodynamic status, and end-organ perfusion in patients with refractory advanced heart failure. Hospital readmission is an important measure of the intensity of LVAD support care. We analyzed readmissions of 148 patients (mean age, 53.6 ± 12.7 yr; 83% male) who received a HeartMate II LVAD from April 2008 through June 2012. The patients had severe heart failure; 60.1% were in Interagency Registry for Mechanically Assisted Circulatory Support class 1 or 2. All patients were observed for at least 12 months, and readmissions were classified as planned or unplanned. Descriptive and multivariate regression analyses were used to identify predictors of unplanned readmission. Twenty-seven patients (18.2%) had no readmissions or 69 planned readmissions, and 121 patients (81.8%) had 460 unplanned readmissions. The LVAD-related readmissions were for bleeding, thrombosis, and anticoagulation (n=103; 49.1%), pump-related infections (n=60; 28.6%), and neurologic events (n=28; 13.3%). The readmission rate was 2.1 per patient-year. Unplanned readmissions were for comorbidities and underlying cardiac disease (54.3%) or LVAD-related causes (45.7%). In the unplanned-readmission rate, there was no significant difference between bridge-to-transplantation and destination-therapy patients. Unplanned readmissions were associated with diabetes mellitus (odds ratio [OR]=3.3; P=0.04) and with shorter mileage from residence to hospital (OR=0.998; P=0.046). Unplanned admissions for LVAD-related sequelae and ongoing comorbidities were common. Diabetes mellitus and shorter distance from residence to hospital were significant predictors of readmission. We project that improved management of comorbidities and of anticoagulation therapy will reduce unplanned readmissions of LVAD patients in the future.

Comparison of outcomes after heart replacement therapy in patients over 65 years old

BACKGROUND

There are currently no well-defined, evidence-based guidelines for management of end-stage heart failure in patients over 65, and the decisions to use mechanical circulatory support with left ventricular assist device (LVAD), either as a bridge to transplantation or destination therapy, or isolated heart transplantation (HTx) remain controversial. We aimed to compare the outcomes after the implementation of three heart replacement strategies in this high-risk population.

METHODS

We conducted a retrospective cohort study of all patients between the ages of 65 and 72 receiving a continuous-flow LVAD as bridge to transplantation or destination therapy or isolated HTx at our center between 2005 and 2012. The patients were stratified according to treatment strategy into three groups: group D (destination LVAD, n = 23), group B (bridge to transplantation LVAD, n = 43), and group H (HTx alone, n = 47). The primary outcomes of interest were survival to discharge and 2-year overall survival.

RESULTS

The patients in group D were significantly older, had a higher prevalence of ischemic cardiomyopathy, and had a higher pulmonary vascular resistance than did patients in groups B or H. There were no significant differences between groups in survival to discharge (87% D vs 83.7% B vs 87.2% H, p = 0.88) or 2-year overall survival (75.7% D vs 68.7% B vs 80.9% H, log-rank p = 0.47). The incidence rates of readmission were 1.1 events/patient·year in group D and 0.5 events/patient·year in group H.

CONCLUSIONS

There was no significant difference in perioperative, short-term, and medium-term survival between the treatment groups. However, the LVAD patients had a higher incidence of readmission. Larger trials are needed to refine differences in long-term survival, quality of life, and resource utilization for elderly patients requiring heart replacement therapy.

Functional status in left ventricular assist device-supported patients: a literature review

The prevalence of advanced heart failure (HF) is increasing because of the aging population and improvements in HF management strategies. Left ventricular assist device (LVAD) technology and management continue to advance rapidly, and it is anticipated that the number of LVAD implants will increase. LVADs have been demonstrated to extend life and improve outcomes in patients with advanced HF. The purpose of this article is to review and synthesize the evidence on impact of LVAD therapy on functional status. Significant functional gains were demonstrated in patients supported by LVAD throughout the 1st year, with most improvement in distance walked and peak oxygen consumption demonstrated in the 1st 6 months. Interventions to enhance exercise performance have had inconsistent effects on functional status. Poor exercise performance was associated with increased risk of adverse events. Functional status improved with LVAD therapy, although performance remained substantially reduced compared with age-adjusted norms. There is tremendous need to enhance our understanding of factors influencing functional outcomes in this high-risk population.

Change in health-related quality of life from before to after destination therapy mechanical circulatory support is similar for older and younger patients: analyses from INTERMACS

BACKGROUND

Destination therapy left ventricular assist devices (DT LVADs) are being implanted in older adults on an increasing basis. Older patients have a higher risk for mortality and morbidity post-LVAD, which may impact their health-related quality of life (HRQOL). We aimed to determine the change in HRQOL by age from before implant to 1 year after DT LVAD implant and identify factors associated with the change.

METHODS

Data were collected from 1,470 continuous-flow DT LVAD patients at 108 institutions participating in INTERMACS from January 21, 2010 to March 31, 2012. Patients were divided into three cohorts: <60 years of age (n = 457); 60 to 69 years of age (n = 520); and ≥70 years of age (n = 493). HRQOL was measured using the generic EuroQol instrument (EQ-5D-3L). Data were collected pre-implant and 3, 6 and 12 months post-implant. Statistical analyses included descriptive statistics, Kaplan-Meier survival analyses and multivariable regression analyses.

RESULTS

HRQOL improved in all patients. Generally, older patients reported better HRQOL than younger patients pre-implant (≥70 years: mean 40; 60 to 69 years: mean 33; and <60 years: mean 31; p < 0.0001) and 1 year post-implant (≥70 years: mean 77; 60 to 69 years: mean 72; <60 years: mean 70; p = 0.01) using the EQ-5D visual analog scale (VAS), with 0 = worst imaginable health state and 100 = best imaginable health state. The magnitude of improvement in EQ-5D scores from pre-implant to 1-year post-LVAD implant was similar in all age groups (≥70 years: mean change 33; 60 to 69 years: mean change 35; <60 years: mean change 35; p = 0.77). Factors associated with improvement in HRQOL from before to 1 year after implant were a lower VAS score pre-implant and fewer rehospitalizations post-implant (R(2) = 61.3%, p < 0.0001).

CONCLUSIONS

Older patients reported better HRQOL than younger patients before and after LVAD implantation. The magnitude of improvement was similar for all age groups, with >70% of all patients showing clinically significant increases (>10 points on the VAS). Rehospitalization appears to reduce the magnitude of improvement.