Relation Between Frailty and 1-Year Outcomes After Implantation of a Left Ventricular Assist Device

Predictive ability of Mini-Cog for postoperative delirium: A systematic review and meta-analysis

AIM

This study aims to determine the predictive value of the preoperative Mini-Cognitive Assessment Instrument (Mini-Cog) for postoperative delirium (POD), a significant complication in older surgical patients. Given its widespread recommendation despite unclear predictive utility, we will conduct the first meta-analysis to synthesize the available evidence.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. Electronic databases (Medline, CINAHL, Cochrane Library, and Web of Science) were searched from inception to May 2024. Studies evaluating the association between preoperative Mini-Cog scores and POD were included. Two independent reviewers performed study selection and data extraction. The methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Random-effects models were used to calculate pooled odds ratios (ORs), sensitivity, and specificity. Sensitivity analyses were performed based on standardized cutoff values and POD assessment methods.

RESULTS

Sixteen studies involving 4980 patients were included. Participants' mean/median ages ranged from 70 to 80 years, and the percentage of patients scoring below the Mini-Cog cutoff varied from 12.5% to 60.5%. Low Mini-Cog scores were significantly associated with increased POD risk (OR = 3.79; 95% confidence interval [CI] = 2.81-5.12; I2 = 57%). The Mini-Cog demonstrated a pooled specificity of 0.80 and sensitivity of 0.50 for POD prediction. Sensitivity analysis of studies using standardized cutoffs (<3) and validated POD assessment tools yielded an OR of 3.40 (95% CI = 2.56-4.53). Half of the included studies showed a low risk of bias across all QUADAS-2 domains. Publication bias assessment using funnel plots and Egger's test showed no significant bias.

CONCLUSIONS

The Mini-Cog shows moderate predictive ability for POD, with high specificity but limited sensitivity. While it may be valuable as part of comprehensive preoperative assessment, its moderate sensitivity suggests it should not be used as the sole predictor. The variability in surgical populations and assessment methods highlights the need for standardization. Future research should focus on establishing consistent methodologies and exploring the Mini-Cog's efficacy in specific surgical populations to enhance its clinical utility in POD risk stratification. Geriatr Gerontol Int 2025; ••: ••-••.

Impact of Frailty in Patients With Continuous-Flow Left Ventricular Assist Device Therapy in End-Stage Heart Failure: A Systematic Review and Meta-Analysis

BACKGROUND

Frailty, marked by increased vulnerability and reduced physiological reserve, is common in end-stage heart failure patients. Continuous flow left ventricular assist devices (LVADs) have improved outcomes, but the impact of frailty on these outcomes is unclear. This systematic review and meta-analysis investigate the effect of frailty on clinical outcomes in patients undergoing LVAD therapy.

METHODS

Following PRISMA guidelines, we searched PubMed, Cochrane, EMBASE, MEDLINE, and Google Scholar up to September 2023 for studies comparing frail and non-frail patients undergoing LVAD implantation. Data on mortality, hospital length of stay, intubation duration, bleeding, infection, and readmission rates were extracted and analyzed using the Mantel-Haenszel random-effects model, with heterogeneity assessed by the I2 statistic.

RESULTS

Fifteen studies involving 3458 patients were included. Frailty was significantly associated with higher long-term mortality (OR: 2.12; 95% CI: 1.17-3.83; p = 0.01), but not with short-term mortality (OR: 1.61; 95% CI: 0.71-3.65; p = 0.26), hospital length of stay (MD: 1.93; 95% CI: -9.83 to 13.68; p = 0.75), or intubation duration (MD: 34.28; 95% CI: -1.15-69.71; p = 0.06). No significant differences were found in bleeding (OR: 1.76; 95% CI: 0.76-4.10; p = 0.19), infection (OR: 0.44; 95% CI: 0.11-1.84; p = 0.26), or readmission rates (OR: 1.07; 95% CI: 0.78-1.46; p = 0.68).

CONCLUSION

Frail patients with LVADs have higher long-term mortality but similar short-term outcomes, hospital stays, intubation times, bleeding, infection, and readmission rates compared to non-frail patients. These findings highlight the need for tailored strategies to improve outcomes in frail LVAD patients and suggest further research on frailty interventions.

Examining Long-Term Influences of Frailty on Outcomes for Adults Undergoing Left Ventricular Assist Device Therapy

BACKGROUND

Frailty is common in adults with end-stage heart failure receiving a left ventricular assist device (LVAD). Short-term studies show frailty reversal post-LVAD. Little is known about long-term frailty and how frailty relates to key LVAD outcomes, including depression, quality of life (QoL), and cognition beyond 6 months.

OBJECTIVE

The purpose of this study was to examine physical frailty, depression, QoL, and cognition from pre-LVAD implantation to 3, 6, and 12 months post-LVAD implantation.

METHODS

Clinical data and measures of physical frailty, depression, QoL, and cognition pre- and post-LVAD were extracted from an existing institutional database. Descriptive statistics and tests for statistical significance were used to describe and compare changes over time. Frailty trajectories were identified to describe physical frailty from pre-LVAD to 12 months post-LVAD.

RESULTS

The sample (n = 46) was predominantly male (76%), with a mean age of 64.7 ± 11 years, and over half (n = 25) were physically frail. Physical frailty was reduced by nearly half at 12 months. Frailty, depression, and QoL significantly improved at all time points (P < .001). Improvements in cognition did not reach statistical significance. Recipients of LVAD without improvement in frailty exhibited worse depression, QoL, and cognition scores at 12 months compared with those not frail pre-LVAD or no longer frail post-LVAD implantation.

CONCLUSION

Some recipients of LVADs experienced physical frailty reversal with benefits sustained long-term. Those without improvement recorded worse long-term patient-reported outcomes. Identifying factors that predict physical frailty response to LVAD implantation is a key area of future research.

Durable left ventricular assist devices as a bridge to transplantation: what to expect along the way?

INTRODUCTION

The scarcity of donors coupled with the improvements in left ventricular assist devices (LVAD) technology has led to the use of LVAD as a bridge to transplantation (BTT).

AREAS COVERED

The authors provide an overview of the current status of LVAD BTT implantation with special focus ranging from patient selection and pre-implantation optimization to post-transplant outcomes.

EXPERT OPINION

The United Network for Organ Sharing 2018 policy amendment resulted in a significant reduction in the number of LVADs used for BTT in the US. To overcome this issue, modifications in the US allocation policy to consider factors such as days on device support, age, and type of complications may be necessary to potentially increase implantation rates.

Frailty in the cardiac intensive care unit: assessment and impact

Frailty, a clinical syndrome of increased vulnerability, due to diminished cognitive, physical, and physiological reserves is a growing concern in the cardiac intensive care unit (CICU). It contributes to morbidity, mortality, and complications and often exerts a bidirectional association with cardiovascular disease. Although it predominately affects older adults, frailty can also be observed in younger patients <65 years of age, with approximately 30% of those admitted in CICU are frail. Acute cardiovascular illness can also impair physical and cognitive functioning among survivors and these survivors often suffer from frailty and functional declines post-CICU discharge. Patients with frailty in the CICU often have higher comorbidity burden, and they are less likely to receive optimal therapy for their acute cardiovascular conditions. Given the significance of this geriatric syndrome, this review will focus on assessment, clinical outcomes, and interventions, in an attempt to establish appropriate assessment, management, and resource utilization in frail patients during and after CICU admission.

Association between natriuretic peptides and C-reactive protein with frailty in heart failure: a systematic review and meta-analysis

BACKGROUND

Heart failure (HF) and frailty are accompanied by a bidirectional relationship, sharing common risk factors including elevated levels of natriuretic peptides and inflammation. The aim of this study was to compare biomarkers associated with poor clinical outcomes, that is, plasma brain natriuretic peptide (BNP), N-terminal-pro B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP) in patients with HF and frailty vs. patients with HF without frailty.

METHODS

From inception until July 2023, PubMed, Scopus, Web of Science, and Cochrane Library a systematic literature search was conducted. To evaluate whether frailty is linked with greater levels of BNP, NT-proBNP, and CRP, a meta-analysis using a random-effects model was used to calculate the pooled effects (CRD42023446607).

RESULTS

Fifty-three studies were included in this systematic review and meta-analysis. Patients with HF and frailty displayed significantly higher levels of BNP (k = 11; SMD: 0.53, 95%CI 0.30-0.76, I2 = 86%, P < 0.01), NT-proBNP (k = 23; SMD: 0.33, 95%CI 0.25-0.40, I2 = 72%, P < 0.01), and CRP (k = 8; SMD: 0.30, 95%CI 0.12-0.48, I2 = 62%, P < 0.01) vs. patients with HF without frailty. Using meta-regression, body mass index (BMI) and age were deemed potential moderators of these findings.

CONCLUSIONS

Frailty in HF is linked to increased concentrations of BNP, NT-proBNP, and CRP, which have been epidemiologically associated with adverse outcomes. The increased risk of NYHA III/IV classification further emphasizes the clinical impact of frailty in this population.

Depressive symptoms, right ventricular function, and muscular strength are associated with peak oxygen uptake in patients with implantable left ventricular assist devices

BACKGROUND

Left ventricular assist device (LVAD) implantation is among the most effective treatment options for patients with severe heart failure. Although previous studies have examined the factors related to peak oxygen uptake (peak VO2 ), they were limited by the few patients involved and their focus on medical and physical functions. Therefore, this study comprehensively examined the factors associated with peak VO2 , which is an important prognostic factor in patients with implantable LVADs.

METHODS

Eighty-nine patients who underwent initial LVAD implantation and were eligible for cardiopulmonary exercise testing (CPX) between May 2014 and September 2021 were included. The patients' mean age was 48 ± 12 years, and 70% were males. Based on previous studies, the cut-off was set at 12 and 14 mL/kg/min for patients taking β-blocker and those not taking β-blockers, respectively. Furthermore, factors associated with peak VO2 were examined using multivariate logistic regression analysis.

RESULTS

The mean time from surgery to CPX administration was 73 ± 40 days. The high group had a higher cardiac index, right ventricular stroke work index (RVSWI), and isometric knee extensor muscular strength and lower Patient Health Questionnaire-9 (PHQ-9) and B-type natriuretic peptide values than the low group. Multivariate logistic regression analysis showed that RVSWI and KEMS were positively correlated, whereas PHQ-9 was negatively associated with peak VO2 .

CONCLUSION

Right ventricular function, depressive symptoms, and lower limb muscular strength were associated with exercise capacity in patients with implantable LVADs.

Impairments identified by comprehensive geriatric assessment in potential candidates for left ventricular assist device and heart transplantation

Background

The aim of this study was to assess the prevalence of frailty and other impairments in potential left ventricular assist device (LVAD) and heart transplantation (HTx) candidates by performing a preoperative comprehensive geriatric assessment (CGA) and reviewing the treatment recommendations resulting from the CGA.

Methods and results

This cross-sectional study included 73 patients aged ≥40 years who received a CGA as part of the patient selection procedure for LVAD and HTx. In every patient, a conclusion comprising frailty and other impairments was formulated based on the medical, mental, functional, and social domains and recommendations were made. The mean age was 58 years (range 40-71) and 70 % were male. In 97 % of patients, at least one impairment was identified by the CGA. The most common impairments were polypharmacy, high morbidity burden, reduced renal function, osteopenia, depression, poor quality of life, reduced functionality, (risk of) malnutrition, reduced grip strength and high caregiver burden. A small proportion of the potential LVAD and HTx candidates were frail (7 % according to Fried's frailty criteria, 6 % according to the Edmonton Frail Scale) and 39 % were pre-frail. The domains for which most impairments were found and the domains for which most treatment recommendations were given matched well, with the functional domain as the frontrunner.

Conclusion

This study showed that most of the potential candidates for LVAD or HTx have impairments on at least one domain of the CGA. Impairments and associated risks can contribute to the decision making process for candidacy for LVAD and HTx.

Impact of Frailty on Left Ventricular Assist Device Clinical Outcomes

Frailty is a clinical syndrome prevalent in older adults and carries poor outcomes in patients with heart failure. We investigated the impact of frailty on left ventricular assist device (LVAD) clinical outcomes. The Nationwide Readmission Database was used to retrospectively identify patients with a primary diagnosis of heart failure who underwent LVAD implantation during their hospitalization from 2014 to 2020. Patients were categorized into frail and nonfrail groups using the Hospital Frailty Risk Score. Cox and logistic regression were used to predict the impact of frailty on inpatient mortality, 30-day readmissions, length of stay, and discharge to a skilled nursing facility. LVADs were implanted in 11,465 patients who met the inclusion criteria. There was more LVAD use in patients who were identified as frail (81.6% vs 18.4%, p <0.001). The Cox regression analyses revealed that LVAD insertion was not associated with increased inpatient mortality in frail patients (hazard ratio 1.15, 95% confidence interval 0.81 to 1.65, p = 0.427). Frail patients also did not experience a higher likelihood of readmissions within 30 days (hazard ratio 1.15, 95% confidence interval 0.91 to 1.44, p = 0.239). LVAD implantation did not result in a significant increase in inpatient mortality or readmission rates in frail patients compared with nonfrail patients. These data support continued LVAD use in this high-risk patient population.

Disentangling Heart Failure and Physical Frailty: Prospective Study of Patients Undergoing Percutaneous Mitral Valve Repair

BACKGROUND

Frailty and heart failure share pathophysiology and clinical characteristics.

OBJECTIVES

The aim of this study was to analyze the contribution of heart failure to the physical frailty phenotype by examining patients with heart failure before and after percutaneous mitral valve repair (PMVR).

METHODS

Frailty according to the Fried criteria (weight loss, weakness, exhaustion, slowness, and low activity) was assessed in consecutive patients before and 6 weeks after PMVR.

RESULTS

A total of 118 of 258 patients (45.7%) (mean age: 78 ± 9 years, 42% female, 55% with secondary mitral regurgitation) were frail at baseline, which significantly decreased to 74 patients (28.7 %) at follow-up (P < 0.001). The frequency of frailty domains slowness, exhaustion, and inactivity significantly decreased, whereas weakness remained unchanged. Baseline frailty was significantly associated with comorbidities, N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, and functional capacity, whereas frailty after PMVR was not associated with NT-proBNP levels. Predictors of postprocedural reversibility of frailty were NYHA functional class 

CONCLUSIONS

Treatment of mitral regurgitation in patients with heart failure is associated with almost a halved burden of physical frailty, particularly in patients with a less advanced phenotype. Considering the prognostic relevance of frailty dynamics, this data warrants further evaluation of the concept of frailty as a primary treatment target.

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Key Words

• frailty
• heart failure
• percutaneous mitral valve repair

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MESH Headings

• Humans
• Female
• Male
• Mitral Valve Insufficiency/complications
• Mitral Valve Insufficiency/surgery
• Mitral Valve/surgery
• Prospective Studies
• Frailty/complications
• Heart Failure/complications
• Heart Failure/surgery
• Treatment Outcome

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Affiliation(s)

Clemens Metze Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
Christos Iliadis Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
Maria I Körber Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
Jennifer von Stein Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
Marcel Halbach Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
Stephan Baldus Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
Roman Pfister Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany.

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Impact of Fried Frailty Phenotype on Postoperative Outcomes After Durable Contemporary Mechanical Circulatory Support: A Single-Center Experience

Background

Frailty is prevalent in advanced heart failure patients and may help distinguish patients at risk of worse outcomes. However, the effect of frailty on postoperative clinical outcomes is still understudied. Therefore, we aim to study the relationship between frailty and postoperative clinical outcomes in patients undergoing long-term mechanical circulatory support (MCS).

Methods

Forty-six patients undergoing durable MCS (left ventricular assist device and total artificial heart) placement at our medical center were assessed for frailty pre-implant. Frailty was defined as ≥ 3 physical components of the Fried frailty phenotype. Our primary endpoint is 1 year of survival post-implant. Secondary endpoints include 30-day all-cause rehospitalization, pump thrombosis, neurological event (stroke/transient ischemic attack), gastrointestinal bleeding, and driveline infection within 12 months post-MCS support.

Results

Of the 46 patients, 32 (69%) met the criteria for frailty according to Fried. The cohort's median age was 67.0 years. The frail group had statistically significant lower left ventricular ejection fraction (LVEF) (11% vs. 20%, P = 0.017) and lower albumin (3.5 vs. 4.0 g/dL, P = 0.021). The frail cohort also had significantly higher rates of comorbid chronic kidney disease (47% vs. 7%, P = 0.016). There were no differences between the frail vs. non-frail group in terms of 30-day readmission rates (40% vs. 39%, P = 0.927) and 1-year post-intervention survival (log-rank, P = 0.165). None of the other secondary endpoints reached statistical significance, although the incidence of gastrointestinal bleed (24% vs. 16%, P = 0.689) and pump thrombosis (8% vs. 0%, P = 0.538) were higher in the frail group.

Conclusions

Preoperative Fried frailty was not associated with readmission at 30 days, mortality at 365 days, and other postoperative outcomes in long-term durable MCS patients. Findings may need further validation in larger studies.

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

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.