Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions

DeFilippis, Ersilia M.; Nakagawa, Shunichi; Maurer, Mathew S.; Topkara, V.K.

doi:10.1111/jgs.16105

Cited by 15 publications

(18 citation statements)

References 97 publications

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“…The AATS/ISHLT guidelines comment on the association between cachexia and poor post-operative outcomes ( 7 ), but frailty is a clinical syndrome that is parallel to, and not defined by, cachexia ( 10 , 11 ), and is associated with poorer outcomes post-LVAD ( 12 , 13 ). Standardized tools for evaluation of frailty include gait speed testing and hand grip strength testing, ( 11 , 13 ) though it is unknown how commonly frailty testing is performed as a part of pre-LVAD evaluation ( 14 ). The results of our study emphasize the importance of structured assessments of frailty prior to launching the LVAD/HT evaluation process.…”

Section: Discussionmentioning

confidence: 99%

Bridge to nowhere: A retrospective single-center study on patients using chronic intravenous inotropic support as bridge therapy who do not receive surgical therapy

Rao

Singh

Maini

et al. 2022

Front. Cardiovasc. Med.

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BackgroundMany patients with advanced heart failure (HF) are administered chronic intravenous inotropic support (CIIS) as bridge to surgical therapy; some ultimately never receive surgery. We aimed to describe reasons patients “crossover” from CIIS as bridge therapy to palliative therapy, and compare end-of-life outcomes to patients initiated on CIIS as palliative therapy.MethodsSingle-institution, retrospective cohort study of patients on CIIS as bridge or palliative therapy between 2010 and 2016; data obtained through review of health records and multi-disciplinary selection meeting minutes, was analyzed using descriptive and inferential statistics.ResultsOf 246 patients discharged on CIIS as bridge therapy, 37 (16%) (male n = 28, 76%; African American n = 22, 60%) ultimately never received surgery. 67 matched patients on CIIS as palliative therapy were included for analysis (male n = 47, 70%; African American n = 47, 70%). The most common reasons for “crossover” from CIIS as bridge therapy to palliative therapy were frailty (n = 10, 27%), cardiac arrest (n = 5, 13.5%), and progressive non-cardiac illnesses (n = 6, 16.2%). A similar percentage of patients in the bridge (n = 28, 76%) and palliative (n = 48, 72%) groups died outside the hospital (P=0.66); however, fewer bridge patients received hospice care compared to the palliative group (35% vs 69%, P < 0.001). Comparing patients who died in the hospital, bridge patients (n = 9; 100%) were more likely to die in the intensive care unit than palliative patients (n = 8; 42%) (P < 0.001).ConclusionPatients on CIIS as bridge therapy who do not ultimately receive surgical therapy “crossover” to palliative intention due to frailty, or development of or identification of serious illnesses. Nevertheless, these “bridge to nowhere” patients are less likely to receive palliative care or hospice and more likely to die in the intensive care unit than patients on CIIS as palliative therapy.

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Section: Discussionmentioning

confidence: 99%

Bridge to nowhere: A retrospective single-center study on patients using chronic intravenous inotropic support as bridge therapy who do not receive surgical therapy

Rao

Singh

Maini

et al. 2022

Front. Cardiovasc. Med.

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“…Left Ventricular Assist Devices are indicated for patients with advanced stage heart failure. Medical optimization can include renin angiotensinaldosterone system antagonists, sympathetic nervous system antagonists, beta blockers [1,[4][5][6][7][8]. Cardiac resynchronization therapy is often used in chronic heart failure candidates to stave off final implantation [1,[4][5][6][7][8].…”

Section: Introductionmentioning

confidence: 99%

“…Medical optimization can include renin angiotensinaldosterone system antagonists, sympathetic nervous system antagonists, beta blockers [1,[4][5][6][7][8]. Cardiac resynchronization therapy is often used in chronic heart failure candidates to stave off final implantation [1,[4][5][6][7][8]. In end-stage heart failure, conventional medical therapies have a mortality at 2 years of almost 100% [9].…”

Section: Introductionmentioning

confidence: 99%

Anesthesia for Non-Cardiac Surgery for the LVAD Patient

Kathryn¹,

Silvonek²

2023

Updates in Anesthesia - The Operating Room and Beyond

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Heart failure is poorly tolerated and end stage heart failure (classified as New York Heart Association (NYHA) class IV) has a two-year survival with medical therapy that approaches 0%. Innovation in this sphere has yielded mechanical therapies, principally the left ventricular assist device (LVAD). In the last decade one-year survival rates of Left ventricular assist device patients have increased from 52–83%. As this therapy is more commonly used to treat advanced heart failure, coupled with the increase in patient survival after implantation, patients are increasingly encountered in the peri-operative arena requiring anesthesia for non-cardiac surgeries. The goal of this chapter is to provide the non-cardiac trained anesthesia provider a primer on what an LVAD is, how it functions, the physiological changes that occur with implantation, and considerations for administering anesthesia to patients with LVADs for non-cardiac surgery. Review of articles from 2018 to 2022 found from a search on PubMed and Google Scholar using the keywords: “Left Ventricular Assist Device”, “LVAD”, “anesthesia”, “non-cardiac surgery”, “Doppler blood pressure measurement”, “VAD coordinator”. Non-cardiac trained anesthesia providers can safely administer the anesthetics to LVAD patients undergoing non-cardiac surgery as long as appropriate considerations are taken.

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“…Left ventricular assist device (LVAD) implantation has been reported to be associated with improved functional capability, survival, and quality of life in subjects with stage D heart failure 1–3 . In addition, LVAD as destination therapy (DT) is acceptable for the management of patients with advanced heart failures that are not eligible for heart transplantation 4,5 . Although, not all patients are alike; physiological determinants, including frailty, should be considered in the risk stratification of patients with advanced heart failure to determine those likely to benefit from such interventions 4 …”

Section: Introductionmentioning

confidence: 99%

“…[1][2][3] In addition, LVAD as destination therapy (DT) is acceptable for the management of patients with advanced heart failures that are not eligible for heart transplantation. 4,5 Although, not all patients are alike; physiological…”

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confidence: 99%

The prognostic value of clinical frailty scale and outcomes in older patients undergoing left ventricular assist device implantation

et al. 2022

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Objectives Heart failure impacts patients’ functional capabilities, ultimately leading to frailty. The use of a left ventricular assist device (LVAD) is acceptable as both destination therapy and bridge to transplant in heart failure management. We aim to evaluate the prognostic value of the Clinical Frailty Scale (CFS) on outcomes in older patients undergoing implantation of LVAD. Methods We conducted a retrospective chart review of patients ≥ 60 years old that underwent LVAD implantation at our medical center from May 1, 2018, to October 30, 2020. CFS was retrospectively assigned before LVAD placement and CFS scores > 4 was considered frail. Kaplan–Meier curves and Cox regression were used to analyze 1‐year survival estimates. Results Forty percent of the cohort was classified as frail according to CFS. Thirty‐day re‐admission rates were comparable between frail and non‐frail patients (46% vs 35%; P = 0.419). 1‐year survival was lower in the frail vs non‐frail group (log rank, P = 0.017). On Cox analysis, only frailty was associated with 1‐year post‐intervention mortality (hazard ratio [HR] = 5.64, 95% confidence interval [CI] = 1.131–28.212; P = 0.035). Conclusions CFS‐defined frailty was associated with increased risk of 1‐year mortality after LVAD implantation. CFS may be a valuable tool in the frailty assessment for risk stratification of patients undergoing LVAD implantation. Multicenter studies are required to validate these findings.

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Left Ventricular Assist Device Therapy in Older Adults: Addressing Common Clinical Questions

Cited by 15 publications

References 97 publications

Bridge to nowhere: A retrospective single-center study on patients using chronic intravenous inotropic support as bridge therapy who do not receive surgical therapy

Bridge to nowhere: A retrospective single-center study on patients using chronic intravenous inotropic support as bridge therapy who do not receive surgical therapy

Anesthesia for Non-Cardiac Surgery for the LVAD Patient

The prognostic value of clinical frailty scale and outcomes in older patients undergoing left ventricular assist device implantation

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