Bridging to transplantation with left ventricular assist devices: Outcomes in patients aged 60 years and older

Reviewing the use of ventricular assist devices in the elderly: where do we stand today?

INTRODUCTION

Implantation of left ventricular assist devices (LVADS) in older patients appears to be an attractive option in the wake of donor shortage and increasing incidence and prevalence of end stage heart failure. Since the inception of the artificial heart program half a century ago tremendous progress in research and development has led to utilization of more sophisticated devices. VADs have therefore emerged as a successful therapy for extending life with meaningful quality. Areas covered: This review will address the use of LVADS as a bridge to transplantation, destination therapy and comparison of LVAD therapy with alternate list heart transplantation in the elderly population. Expert commentary: Age >70 years is an important aspect when assessing LVAD risk, but other characteristics appear to be better predictors of LVAD survival. Elevated pre-operative creatinine, bilirubin and ischemic etiology predispose to a higher risk of mortality. Creatinine has been shown to be a very powerful predictor in post LVAD survival. Based on the existing literature, the authors suggest an algorithm which could be useful when evaluating patients for LVAD implantation.

Left ventricular assist pump pocket infection: conservative treatment strategy for destination therapy candidates

BACKGROUND

Heart failure is a major cause of mortality and morbidity, particularly among patients with advanced disease and no access to cardiac transplantation. LVAD implantation is not only a bridge-to-transplantation option for patients awaiting a heart donor, but is often used as bridge-to-destination therapy in patients unsuited for transplantation for various reasons. LVAD infection is considered the second-most common cause of death in patients who survive the initial 6 months on LVAD support. Few reports describe the indications for chronic suppressing antibiotic therapy, device exchange, methods for exchanging infected devices, post-exchange antimicrobial management status, and the outcomes of such patients.

CASE PRESENTATION

This is the case of a 74-year-old male patient with numerous comorbidities who received urgent surgical management for severe heart failure with a HeartMate II. Six months later he developed an LVAD pump infection with methicillin-resistant Staphylococcus epidermidis, which was diagnosed with leucocyte scintigraphy. The patient received an omental graft over the LVAD and a chronic suppressive antibiotic regime. A marked leukocyte scintigraphy showed the infection's regression 6 months after the initiation of antibiotic treatment.

DISCUSSION

We concisely reviewed the driveline infections and the main aspects of the LVAD pump infection. We reviewed options for conservative and nonconservative management and showed that conservative management of the LVAD pump infection is possible.

CONCLUSIONS

There are no defined recommendations for the management of LVAD pump infection. This case is among the few in the literature showing that conservative treatment of an LVAD pump infection is possible.

Left ventricular assist device-related infections: past, present and future

Over the last decade, left ventricular assist device (LVAD) implantation has emerged as an alternative treatment strategy in patients with advanced heart failure irrespective of their transplant eligibility. However, success and applicability of this therapy is largely limited by high complication rates associated with these devices. Although superior outcomes have been achieved with the second-generation continuous-flow LVADs, device-related infections continue to be a prevalent complication in this patient population and contribute significantly to the financial burden of this therapy due to an increased need for hospitalizations and surgical interventions. Patient selection, device design and LVAD-induced immune system dysfunction appear to be major risk factors for the development of device-related infections. Improvements in device design and better patient selection strategies, particularly with respect to identifying individuals with genetic susceptibility to device-related infections, may further reduce this prevalent complication and improve outcomes in patients with advanced heart failure.

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

OBJECTIVES

The primary objective of this study was to determine outcomes in left ventricular assist device (LVAD) patients older than age 70 years.

BACKGROUND

Food and Drug Administration approval of the HeartMate II (Thoratec Corporation, Pleasanton, California) LVAD for destination therapy has provided an attractive option for older patients with advanced heart failure.

METHODS

Fifty-five patients received the HeartMate II LVAD between October 5, 2005, and January 1, 2010, as part of either the bridge to transplantation or destination therapy trials at a community hospital. Patients were divided into 2 age groups: ≥ 70 years of age (n = 30) and < 70 years of age (n = 25). Outcome measures including survival, length of hospital stay, adverse events, and quality of life were compared between the 2 groups.

RESULTS

Pre-operatively, all patients were in New York Heart Association functional class IV refractory to maximal medical therapy. Kaplan-Meier survival for patients ≥ 70 years of age (97% at 1 month, 75% at 1 year, and 70% at 2 years) was not statistically different from patients <7 0 years of age (96% 1 month, 72% at 1 year, and 65% at 2 years, p = 0.806). Average length of hospital stay for the ≥ 70-year age group was 24 ± 15 days, similar to that of the < 70-year age group (23 ± 14 days, p = 0.805). There were no differences in the incidence of adverse events between the 2 groups. Quality of life and functional status improved significantly in both groups.

CONCLUSIONS

The LVAD patients ≥ 70 years of age have good functional recovery, survival, and quality of life at 2 years. Advanced age should not be used as an independent contraindication when selecting a patient for LVAD therapy at experienced centers.