Ventricular Assist Device Implant in the Elderly Is Associated With Increased, but Respectable Risk: A Multi-Institutional Study

Abstract

Background There are an increasing number of elderly patients with end-stage heart failure. Destination mechanical circulatory support is often the only therapy available for these patients who are not transplant candidates. The outcomes after continuous flow left ventricular assist device (CF LVAD) implant in older patients remains unclear. We undertook this multi-institutional study to quantify short-term and midterm outcomes after CF LVAD implant in the elderly. Methods We retrospectively analyzed all patients in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) national registry that underwent implant of a CF LVAD (June 2006 to April 2012). Patients were divided into 2 cohorts based upon age (<70 years [n = 4,439] and ≥70 years (n = 590]). Preoperative, intraoperative, and postoperative variables were analyzed. The primary endpoint, survival, was compared between cohorts. Results Patients age 70 and older were more hemodynamically stable pre-VAD implant as evidenced by INTERMACS profile and inotrope dependence. Perioperative outcomes, including median bypass time (89 vs 89 minutes) and length of stay (0.657 vs 0.657 months) were similar between cohorts (p = not significant). Kaplan-Meier analysis revealed a significant difference in 2-year survival between patients aged 70 years or greater (63%) and less than 70 (71%, p < 0.001). Multivariable Cox proportional hazard analysis revealed age as an independent predictor of mortality during follow-up (p < 0.001). Nonetheless, midterm cumulative survival in the older cohort was still reasonable (63% at 2 years). Conclusions Multi-institutional analysis revealed advanced age as a predictor of increased mortality after CF LVAD implantation. Careful patient selection is critical in the elderly to optimize long-term outcomes after CF LVAD implantation.

Heart Failure in Non-Caucasians, Women, and Older Adults: A White Paper on Special Populations From the Heart Failure Society of America Guideline Committee

“…MCS is also being used increasingly as a bridge to transplant or, more commonly in older patients, as destination therapy. 202 Although some older patients benefit from MCS, 203 the risk of complications, including gastrointestinal bleeding, stroke, and infections, increases with age. 202 In addition, very few patients $80 years old have been treated with MCS, so the value at very elderly ages is unknown.…”

“…202 Although some older patients benefit from MCS, 203 the risk of complications, including gastrointestinal bleeding, stroke, and infections, increases with age. 202 In addition, very few patients $80 years old have been treated with MCS, so the value at very elderly ages is unknown. Similarly as for all patients, consideration of MCS in older patients as destination therapy should be undertaken only after detailed discussion of the risks, benefits, and alternatives, including palliative care and hospice.…”

Pre-operative mortality risk assessment in patients with continuous-flow left ventricular assist devices: Application of the HeartMate II risk score

“…In fact, the current growth of the DT CF-LVAD population 14 can be expected to rise in light of recent studies reporting successful outcomes in more elderly patients. [17][18][19] Understandably, such expansion into more geriatric cases may further limit HMRS validity.…”

Advanced Heart Failure Treatment Options Among the Elderly

“…34 Using the largest allpayer database in the United States, Kilic et al 35 observed comparable mortality, with no independent impact of age on inpatient mortality, when comparing elderly patients (age > 70, n=1,472) to a younger group (age 60-69, n=2,787) supported with continuous-flow LVAD. Somewhat contradictory data was published by Atluri et al, 36 who examined the INTERMACS national registry from 2006 to 2012 and similarly dichotomized patient groups into age > 70 (n=590) and age < 70 (n=4,439). They found that despite higher INTERMACS profiles (indicating less severe illness at time of enrollment), comparable heart bypass time and comparable length of stay, 2-year survival was lower in the older cohort (63% vs 71%, P<0.001).…”