Contemporary outcomes of continuous-flow left ventricular assist devices—a systematic review

Abstract

Background: End stage heart failure is a major cause of morbidity and mortality, and its prevalence is expected to rise with the ageing population. For suitable patients, orthotopic heart transplantation remains the gold standard therapy, however, a paucity of donor organs has led to the development of left ventricular assist devices (LVAD). These devices can be utilized as either a bridge-to-transplant (BTT) or as an alternative to heart transplantation. While these devices can prolong life and improve quality of life, they are associated with a significant number of adverse events. We aim to systematically review the literature to quantify survival and the incidence of adverse events following implantation of continuous-flow LVADs (cf-LVAD).Methods: A systematic review was performed to determine outcomes following implantation of a cf-LVAD.Primary outcomes were survival and frequency of adverse events (such as bleeding, infection, thrombosis, stroke and right ventricular failure). Secondary outcomes included quality of life and assessment of functional status.Results: Sixty-three studies reported clinical outcomes of 9,280 patients. Survival after cf-LVAD varied between studies. Industry-funded trials generally reported better overall survival than the single-and multicenter case series, which showed significant variation. The largest registry report documented twelve, twentyfour and forty-eight-month survival rates of 82%, 72% and 57% respectively. The most commonly reported adverse events were gastrointestinal bleeding (GIB), device-related infection, neurological events and right heart failure (RHF). Bleeding, RHF and infection were the most frequent complications experienced by those supported with cf-LVAD, occurring in up to 35%, 40% and 55% of patients, respectively. Quality of life as measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ) and functional status as measured with the 6-minute walk test (6MWT) improved after cf-LVAD implantation with no decline evident two years after implantation. Conclusions:The paucity of donor hearts has led to the development of left-ventricular assist devices as a BTT or as a destination therapy (DT). Outcomes after cf-LVAD implantation are excellent, with short-term survival comparable to heart transplantation, but long-term survival remains limited due to the incidence of post-implantation adverse events. Despite these complications, quality of life and functional status improve significantly post-implantation and remain improved over the long-term. This study demonstrates the potential benefits of cf-LVAD therapy whilst also identifying adverse events as an area of increased morbidity and mortality.

Does the distance between residency and implanting center affect the outcome of patients supported by left ventricular assist devices? A multicenter Italian study on radial mechanically assisted circulatory support (MIRAMACS) analysis

“…The improvement in Left Ventricular Assist Device (LVAD) outcomes has led to an increasing number of patients who are supported by this long-term mechanical circulatory support and who are able to improve their quality of life, and be reintegrated into their communities, often far from the Implant Center (IC). 1,2 However, patients with LVAD require continuous monitoring and periodic checks in order to prevent and treat as soon as possible any complication related to the device or to the anticoagulation treatment. [1][2][3] Since ICs are more experienced in managing LVAD patients than other healthcare facilities, the distance between patient residency and IC could negatively affect the outcomes.…”

Surgical repositioning of Jarvik 2000 LVAD power supply pedestal following fall trauma

“…4 Among the VAD-specific infections, driveline infection (DLI) is the primary issue, occurring in 5%– 44% of LVAD patients. 3,4 Previous studies show that the location and fixation method of the driveline are crucial factors in the prevention of infections (3.6–8). Jarvik 2000® is proven to have prolonged infection-free survival than other devices since the rigid fixation and the highly vascularized scalp skin reduces the risk of exit site infection.…”

“…These are most commonly bleeding (mainly gastrointestinal), thrombosis, neurological events, right heart failure, and device-related infection. 3 The ISHLT (International Society for Heart and Lung Transplantation) multidisciplinary working group has standardized the definitions of MCS infections and provided a consensus document. 4 Among the VAD-specific infections, driveline infections (DLI) are the primary issue, occurring in 5%– 44% of LVAD patients.…”

“…4 Among the VAD-specific infections, driveline infections (DLI) are the primary issue, occurring in 5%– 44% of LVAD patients. 3,4 Despite its smaller diameter and the special covering of the power cable, the driveline exit site always remains a potential entry point for bacteria. As previous studies have shown, the location and fixation of the driveline is a crucial factor in the prevention of infections.…”

The History of Durable Left Ventricular Assist Devices and Comparison of Outcomes: HeartWare, HeartMate II, HeartMate 3, and the Future of Mechanical Circulatory Support

“…Overall, treatment of end-stage HF with an LVAD consistently improves patient quality of life [ 14 , 15 ]. After receiving LVAD support, patients typically experience improved functional capacity with lesser physical and psychological symptoms, leading to better quality of life [ 16 , 17 , 18 ]. In addition, psychosocial factors have been shown to significantly influence quality of life after LVAD implant.…”