Age related outcome after implantable left ventricular assist system support

Update on ventricular assist device technology

Ventricular assist devices are an important component in the arsenal of therapies to support the failing heart. This article provides an update on the variety of pulsatile, centrifugal, and axial-flow devices available in the United States. Common indications such as Bridge to Recovery and Bridge to Transplant are explored, as are the emerging indications Destination Therapy, Bridge to Decision, and Bridge to Bridge. Ventricular assist devices as support during high-risk percutaneous coronary intervention and the devices that can be rapidly deployed for this support are included. Clinical aspects of patient care including common complications, psychosocial concerns, and ethical considerations are reviewed.

Effect of Age on Outcomes After Left Ventricular Assist Device Placement

The influence of age on outcomes after left ventricular assist device (LVAD) implantation is not well studied. To address this question, we assessed 222 patients who underwent LVAD placement and were divided into quartiles based on age (years): group 1, <or=44; group 2, 45 to 53; group 3, 54 to 59; and group 4, >or=60. Eighty-four patients died on LVAD support. Six- and 12-month survivals for the four groups of LVAD patients were 67.7, 73.7, 49.8, and 38.2, and 49.4, 57.3, 42.7, and 26.2, respectively (all P<.01). Older patients showed a higher risk of infections, embolic strokes, and respiratory complications. They were the least likely to undergo reoperations postimplantation (56%, 53%, 50%, 46%, P=.06). After adjusting for baseline differences between the groups, there was a trend toward increasing mortality with age, which did not reach significance (odds ratio 1.93; 95% confidence interval 0.95 to 3.92 for the oldest quartile as compared with the youngest). In conclusion, these results suggest in the absence of other high risk factors, age alone should not be used as an independent contraindication for LVAD implantation.

Ventricular assistance to bridge to transplantation

In 2001, 2202 heart transplants were performed in the United States, leaving 4137 patients waiting who suffer from 30% annual mortality. Status I, Class IV heart failure patients have a 66% 1-year mortality rate and a survival approximating our worst cancers. Left ventricular assist devices (LVADs) first successfully bridged a patient to transplantation in 1978. LVADs have since functioned primarily thus, minimizing end-organ damage and providing rehabilitation potential for individuals awaiting transplantation. In this role, their effectiveness is well-established: they gain time for patients awaiting donors, preserve end-organ function, and provide potential for a high quality of life in and out of the hospital. This success has been the result of numerous advances in VAD technology, which this article discusses.

New surgical treatments for heart failure

Medical therapy for heart failure is quickly advancing, but long-term survival unfortunately remains poor. New surgical techniques seek to halt and reverse the progression of heart failure. Positron emission tomography has refined patient selection techniques for coronary artery bypass grafting in the failing heart. Left ventricular (LV) remodeling surgery and new devices change the shape of the LV and decrease LV wall stress. Passive restraint devices improve systolic function by preventing ventricular dilatation. LV assist devices have proven to be effective and provide a significantly higher 1-year survival rate when compared with maximal medical therapy. New ideas and devices are defining a new role for surgical treatment of the aging population of the United States and may provide the answer to long-term management of heart failure.

Multicenter experience with the thoratec ventricular assist device in children and adolescents

BACKGROUND

Patient size is 1 determinant in selecting a mechanical circulatory support device. The current pulsatile ventricular assist devices (VADs) were designed primarily for average-sized adults. The flexibility of the Thoratec VAD, however, has encouraged physicians to use it in a significant number of intermediate-sized older children and adolescents.

METHODS

We conducted a retrospective study in 58 children and adolescents <18 years (41 boys, 17 girls) who had been supported with the Thoratec VAD in 27 centers worldwide as of December 1999. Mean patient age was 13.8 years (range, 7 to 17 years), and mean patient weight and body surface area were 51.6 kg (range, 17 to 93 kg) and 1.5 m(2) (range, 0.7 to 2.1 m(2)), respectively.

RESULTS

Thirty-five patients (60%) survived to transplantation and 6 (10%) to recovery of the native heart, respectively; 38 were discharged from the hospital (66%). In the transplanted group, post-transplantation survival was 97%. Patient age and size were not associated with significantly increased risk for death or adverse events. Fifteen patients (27%) had 18 neurologic events during support, and 6 of these were fatal. Left atrial cannulation proved a risk factor for neurologic complications.

CONCLUSIONS

The Thoratec VAD has successfully been used in a large number of children and adolescents with similar morbidity and mortality results as with adults. The risk of neurologic complications may be increased, particularly in patients cannulated in the left atria.