Keeping Left Ventricular Assist Device Acceleration on Track

Stewart, Garrick C.; Stevenson, Lynne Warner

doi:10.1161/circulationaha.110.982512

Cited by 57 publications

(38 citation statements)

References 47 publications

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“…For this ambulatory population in whom death is not imminent, shared decision making about MCS also requires a more measured and individualized consideration of risks and benefits beyond survival. 3 Current MCS decisions for ambulatory patients are seriously constrained by lack of information regarding expected outcomes for comparable patients on contemporary medical therapy without MCS. These uncertainties limit the comfort for physicians to refer and ambulatory patients to accept MCS.…”

Section: Stewart Et Al Profiles In Ambulatory Advanced Heart Failurementioning

confidence: 99%

INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) Profiling Identifies Ambulatory Patients at High Risk on Medical Therapy After Hospitalizations for Heart Failure

Stewart

Kittleson

Patel

et al. 2016

Circ: Heart Failure

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Background— INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles provide important prognostic information for patients with advanced heart failure (HF) receiving mechanical support. The value of INTERMACS profiling has not been shown for patients followed on medical therapy for advanced HF at centers that also offer mechanical circulatory support. Methods and Results— This prospective, observational study enrolled 166 patients with chronic New York Heart Association class III–IV HF, ejection fraction ≤30%, and ≥1 HF hospitalization in the previous year, excluding patients listed for transplant or receiving chronic intravenous inotropic therapy. Subjects were followed for at least 12 months or until death, mechanical support, or transplant. Baseline features, quality of life, and outcomes were compared according to INTERMACS profile. Mean age was 57 years, ejection fraction 18%, and 57% had HF >5 years, whereas 23% of subjects were INTERMACS profile 4, 32% profile 5, and 45% profile 6/7. At 1 year, only 47% of this ambulatory advanced HF cohort remained alive on medical therapy. Patients in INTERMACS profile 4 were more likely to die or require mechanical support, with only 52% of these patients alive without support after the first 6 months. Profile 6/7 patients had 1-year survival of 84%, similar to outcomes for contemporary destination left ventricular assist device recipients. Quality of life using the indexed EuroQol score was poor across profiles 4 to 7, although severe limitation was less common than for ambulatory patients enrolled in INTERMACS before ventricular assist device implantation. Conclusions— Ambulatory patients with systolic HF, a heavy symptom burden, and at least 1 recent HF hospitalization are at high risk for death or left ventricular assist device rescue. INTERMACS profiles help identify ambulatory patients with advanced HF who may benefit from current mechanical support devices under existing indications.

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Section: Stewart Et Al Profiles In Ambulatory Advanced Heart Failurementioning

confidence: 99%

INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) Profiling Identifies Ambulatory Patients at High Risk on Medical Therapy After Hospitalizations for Heart Failure

Stewart

Kittleson

Patel

et al. 2016

Circ: Heart Failure

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“…Orthotopic heart transplantation has been an option for several decades, but the availability of suitable organ donors has limited the number of heart transplants to approximately 2200 per year in North America, which has been stated to be “epidemiologically trivial”[78] when considering the burden of HF in the population. However, left ventricular assist devices (LVAD) can now be used as both a bridge to transplantation (until a suitable organ becomes available) or as destination therapy (LVAD remains in situ until death).…”

Section: Secular Trends In Outcomes After Heart Failure Diagnosismentioning

confidence: 99%

Understanding the Epidemic of Heart Failure: Past, Present, and Future

Dunlay

Roger

2014

Curr Heart Fail Rep

181

121

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Heart failure (HF) is a major public health problem affecting more than 5 million Americans and more than 23 million patients worldwide. The epidemiology of HF is evolving. Data suggests that the incidence of HF peaked in the mid 1990s and has since declined. Survival after HF diagnosis has improved, leading to an increase in prevalence. The case mix is also changing, as a rising proportion of patients with HF have preserved ejection fraction and multimorbidity is increasingly common. After diagnosis, HF can have a profound associated morbidity. Hospitalizations in HF remain both frequent and costly, though they may be declining as a result of preventive efforts. The need for skilled nursing facility care in HF has risen. The role of palliative medicine in the care of patients with advanced HF is evolving as we learn how to best care for this population with a large symptom burden.

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“…Specifically, for patients categorized as INTERMACS profile 1 (“crash and burn” with critical organ hypoperfusion), outcomes with medical therapy are abysmal but risk with chronic durable LVAD therapy is also relatively high, such that most centers have shifted towards temporary forms of MCS to first assess whether these patients can resolve multi-organ failure and recover to a lower INTERMACS profile prior to durable LVAD implantation. 5,13,14 For patients categorized as INTERMACS profiles 2-3 (inotrope dependent) multiple studies have clearly demonstrated superior outcomes with chronic durable LVAD vs. medical therapy 15–18 , and patients falling into these profiles currently account for the largest proportion of patients currently receiving LVAD therapy 10 .…”

Section: The Who What When Why and How Of Optimal Delivery Of Lvamentioning

confidence: 99%

Patient-centered care for left ventricular assist device therapy

Breathett¹,

Allen²,

Ambardekar³

2016

Current Opinion in Cardiology

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Purpose of review Discuss the current status and obstacles that need to be overcome in the future to provide patient-centered care with left ventricular assist device (LVAD) therapy. Recent findings LVADs offer both longer survival and improvements in quality of life for carefully selected patients with inotrope-dependent heart failure (HF). Yet, this technology does not come without significant risk of adverse effects and burdens. Recent observational data comparing LVAD to medical therapy in ambulatory, non-inotrope dependent patients with advanced HF suggest that survival may be similar and changes in quality of life may depend on baseline status. As both LVAD technology and medical therapy continue to evolve, there are many unanswered questions regarding the benefits, risks, and burdens of LVAD therapies in less severe HF populations. Summary Further research is needed to ensure the optimal delivery of LVAD therapy including improved patient selection, implantation timing, device type, and decision support.

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Keeping Left Ventricular Assist Device Acceleration on Track

Cited by 57 publications

References 47 publications

INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) Profiling Identifies Ambulatory Patients at High Risk on Medical Therapy After Hospitalizations for Heart Failure

INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) Profiling Identifies Ambulatory Patients at High Risk on Medical Therapy After Hospitalizations for Heart Failure

Understanding the Epidemic of Heart Failure: Past, Present, and Future

Patient-centered care for left ventricular assist device therapy

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