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Contemporary LVAD Outcomes in an Aging Population
Quick Takes
- In elderly patients, LVADs are associated with increased functional capacity, similar improvements in quality of life, and fewer complications compared with younger patients.
- Patients >65 years who received new-generation full magnetic levitation devices in this analysis had significantly better late survival on support compared with patients who received older LVAD models.
- This study suggests that elderly patients derive sustained benefit from the new smaller, more hemo-compatible LVAD models.
Study Questions:
What is the impact of left ventricular assist device (LVAD) on survival, functional outcomes, and quality of life in current-day clinical practice?
Methods:
The study authors conducted a retrospective cohort analysis on adults (age >18 years) receiving durable LVADs from the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) database. To evaluate practice and outcomes according to patient age at time of implantation, the authors stratified patients by age <65 years, 65-75 years, and >75 years of age. The adjusted survival was the primary outcome. For the primary survival analysis, competing risk using Fine and Gray regression was used to assess the proportion of patients who received transplants, who died, who had cessation of support, or who were still alive on a device. In a secondary survival analysis, Kaplan-Meier curves with log-rank testing were used to assess post-LVAD implantation survival while on support. Secondary outcomes included quality of life rated using a visual analogue scale (where 0 represents “worst health” and 100 “best health”); 6-minute walk distance; stroke; device malfunction; and rehospitalization, stratified by patient age. Median follow-up was 15 months (interquartile range [IQR], 6-32 months).
Results:
The study cohort of 24,408 patients was predominantly male (78%, n = 19,119), white (66%, n = 16,015), and had a median age of 57 ± 13 years. 16,808 (68.9%) patients were aged <65 years, 6,418 (26.3%) patients aged 65-75 years, and 1,182 (4.8%) patients aged >75 years, who were predominantly male (n = 19,119; 78%) and on destination therapy (n = 12,425; 51%). Competing outcomes analysis demonstrated mortality (70% confidence intervals [CIs]) of 34% (33%-34%), 54% (54%-55%), and 66% (64%-68%) for patients aged <65, 65-75, and >75 years, respectively, which improved during the study in patients aged >75 years. Newer-generation devices were associated with reduced late mortality (hazard ratio, 0.35; 95% CI, 0.25-0.49). Stroke, device malfunction or thrombosis, and rehospitalizations decreased with increasing age (all p < 0.01). Median 6-minute walk distance increased from 0 feet (IQR, 0-665 feet) to 1,065 feet (IQR, 642-1,313 feet) (p < 0.001), and quality of life improved from 40 (IQR, 15-60) to 75 (IQR, 60-90) (p < 0.001) after LVAD in all age groups.
Conclusions:
The study authors concluded that in elderly patients, LVADs are associated with increased functional capacity, similar improvements in quality of life, and fewer complications compared with younger patients.
Perspective:
This retrospective study suggests that as LVAD technology improves, durable LVADs may become an important therapeutic option in elderly patients with heart failure with reduced ejection fraction (HFrEF). The next step is to conduct prospective clinical trials with newer, durable LVADs in HFrEF patients above 70 years of age.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Mechanical Circulatory Support
Keywords: Aged, Aging, Cardiac Surgical Procedures, Family Characteristics, Geriatrics, Heart-Assist Devices, Heart Failure, Heart Transplantation, Outcome Assessment, Health Care, Quality of Life, Stroke, Stroke Volume, Survival, Thrombosis
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