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

Study Questions:

Are outcomes of patients older than 70 years of age receiving a HeartMate II left ventricular assist device (LVAD) from a community hospital similar to that of younger patients?

Methods:

This was a post-hoc analysis of patients (n = 55) enrolled into the HeartMate II Bridge to Transplant and Destination Therapy trials, who underwent HeartMate II LVAD implant at a community hospital. Survival, quality of life (Minnesota Living With Heart Failure and Kansas City Cardiomyopathy Questionnaire), functional status (New York Heart Association class, 6-minute walk test distance), and postoperative morbidities were compared between elderly patients ≥70 years of age (n = 30) and younger (n = 25) patients.

Results:

At baseline, the mean age in the elderly group was 76 ± 3.9 years compared with 57 ± 14 years in the younger group (p < 0.001). Elderly patients had higher baseline prealbumin (p = 0.03) and tended to have greater use of cardiac resynchronization therapy (p = 0.06). An ischemic etiology for heart failure tended to be more common in patients ≥70 years of age and they also tended to require less preoperative ventilator, balloon pump, and inotrope supports than younger patients. In the age ≥70 group, 13% had high-risk preoperative Lietz-Miller scores compared with 20% in the younger group (p = 0.72). Concomitant intraoperative procedure burden (e.g., aortic valve patch, tricuspid repair) and bypass times were similar between groups (p > 0.05). In the age ≥70 group, Kaplan-Meier survival at 1 and 2 years was 75% and 70%, respectively, which was similar to that of patients ≤70 years (72% and 65%, respectively; p = 0.81). There was no significant difference in post-LVAD complications, but statistical power was limited. Quality-of-life scores and measures of functional status improved significantly from baseline in both age groups by 6 months postoperative, and no measure was statistically different between groups.

Conclusions:

The authors concluded that advanced patient age should not be used as a contraindication to LVAD support at experienced LVAD centers.

Perspective:

Age has consistently been shown to be a risk factor for poor outcome after LVAD implant. The reasons for this are likely multifactorial: older patients carry less physical reserve in the setting of stress, they have more comorbidities, and their ability to rehabilitate may be less than that of the younger patient. In this study, patients in the elderly group did remarkably well at 1 and 2 years following LVAD, with excellent survival and improvements in quality of life and functional capacity. It is clear that elderly patients were very carefully selected for LVAD support and tended to appear ‘healthier’ than younger patients at baseline. Preoperatively, elderly patients were more hemodynamically stable (less inotrope, ventilator, intra-aortic balloon pump use), with trends for better renal function, better hepatic function, and better nutrition. Thus, very careful selection of the elderly patient can lead to good outcomes after LVAD support. Age should not exclude patients from such therapy. However, identifying the ‘less sick’ elderly patient who is most likely to benefit from LVAD support will require timely referral and timely intervention.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support

Keywords: Prealbumin, Minnesota, Heart-Assist Devices, Hospitals, Community, Comorbidity, Risk Factors, New York, Cardiac Resynchronization Therapy, Heart Transplantation, Postoperative Period, Heart Diseases, Kansas, Cardiomyopathies, Heart Failure, Exercise Test


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