Heart-Assist Devices Underused in Older Patients
Smidt Heart Institute Study Finds Even Elderly Heart Failure Patients Gain Quality-of-Life Benefits With Left Ventricular Assist Devices
A study from the Smidt Heart Institute and the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) that reviewed national data on more than 24,000 patients who had mechanical pumps implanted to treat advanced heart failure found that the pumps significantly improved survival and quality of life, and may be underused in patients ages 75 and older. The research was published online today by JACC, the Journal of the American College of Cardiology.
About 10% of the 6 million people in the U.S. with heart failure have advanced heart failure, meaning conventional therapies such as medications can't improve their condition. Heart transplantation is the gold standard for treating these patients but is a limited resource and not suitable for every patient.
To treat patients—often older patients—who aren't candidates for transplantation, heart surgeons sometimes turn to left ventricular assist devices, also known as LVADs. These mechanical pumps are implanted inside the chest to help the heart pump oxygen-rich blood to the rest of the body.
The devices can make a dramatic difference for many patients.
"I've had some patients in their late 70s, who had previously been very active, and after getting their LVAD sent me pictures of themselves resuming activities they once loved—like travel and sports. One patient sent me a photo of himself on a fishing trip," said Dominic Emerson, MD, associate surgical director of Heart Transplant and Mechanical Circulatory Support in the Smidt Heart Institute and lead author of the study.
Historically, fear of complications such as stroke, bleeding and infection made some physicians hesitant to suggest LVADs as an option for elderly patients. But it’s time to reevaluate which patients might benefit from the devices, said Joanna Chikwe, MD, founding chair of the Department of Cardiac Surgery in the Smidt Heart Institute at Cedars-Sinai and co-lead author of the study.
"At Cedars-Sinai we’ve seen many patients in their 70s do really well with heart transplants, but it isn’t an option for everyone," said Chikwe. "These are the first insights we’re gaining into how well newer-generation devices can work for older patients who can’t get transplants. For many patients with advanced heart failure, newer-generation LVADs are transformational."
To shed light on these improvements, researchers from the Smidt Heart Institute collaborated with the Intermacs team led by James Kirklin, MD, professor of surgery at the University of Alabama at Birmingham, to analyze national data from the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support database. They reviewed information on 24,408 adult patients in the U.S. who received LVADs from January 2010 to March 2020.
"We were able to see really impressive improvements in quality of life in even the most elderly patients, and over time, how patients with newer-generation devices had fewer complications," Emerson said.
Current-generation LVADs are smaller than older models—half the size of a fist, rather than the size of a dinner plate—and use new technology to reduce blood clots and infection.
The researchers found that patients receiving these newer LVADs experienced fewer device failures, less blood clotting within the device, and lower rates of infection and stroke than patients with previous-generation devices. Patients older than 75 experienced even fewer LVAD-related complications than their younger counterparts.
Better Quality of Life
Patient reports about how they felt on a day-to-day basis, and the distance they could walk over six minutes without resting, also suggested improved quality of life.
Before receiving their LVADs, most patients could not walk any significant distance, and many weren't well enough to do a six-minute walk test at all. After implantation of the devices, the median walk distance for the whole patient group increased from zero to 1,000 feet, the equivalent of more than three city blocks.
Patients older than 75 generally were unable to walk quite that far but did manage a median distance of approximately 880 feet, which is still a significant increase.
"That means patients can go out and do things they want to do," Emerson said. "We can all take for granted things like being able to do your own laundry or go to the grocery store, but if you take that away from a person, that's a huge hit to their quality of life and their independence."
Emerson, Chikwe and colleagues hope their results will increase awareness of the benefits of LVADs and their use in older patients with advanced heart failure.
"We believe this is the largest evaluation of quality of life and physical activity after LVAD," said Chikwe. "We hope these findings increase awareness of this great option for elderly heart-failure patients who may not be candidates for heart transplant. Furthermore, our research confirms our clinical experience that newer-generation LVADs can be transformative for patients who have exhausted other heart-failure treatment options."
Funding: The study was funded and designed by The Society of Thoracic Surgeons.
Read more on the Cedars-Sinai Blog: Treatment Options for Heart Valve Disease