Many Eligible HF Patients Would 'Definitely' Consider a LVAD

September 20, 2011

September 20, 2011 (Boston, Massachusetts) — A lot of people with advanced heart failure are not electively implanted with a left ventricular assist device (LVAD) even though they meet the approved indications for one, but apparently many of them would be "enthusiastic" about living with one themselves.

That's according to investigators who looked at questionnaire responses from 150 such ambulatory patients who read a short, nonspecific description of an LVAD and its potential risks and were asked how warm they were to the idea of receiving one, hypothetically [1].

Dr Garrick C Stewart

Not too surprisingly, willingness to consider an LVAD was highest when the respondent was in poorer clinical shape or had a history of frequent HF hospitalization. But a whopping 57% said they would "definitely want" or "probably want" an LVAD based on how they felt at that very moment, said Dr Garrick C Stewart (Brigham and Women's Hospital, Boston, MA) when presenting the study here at the Heart Failure Society of America 2011 Scientific Meeting.

LVADs are currently approved in the US for HF patients with low LVEF and severe functional limitations even if they are "not yet inotrope-dependent," Stewart told heartwire . "But there's been very little penetration of LVAD technology into that group; less than 20% of current LVADs are going into such patients."

But those are the patients who stand to gain the most from the devices, he said. "We think that population is likely to derive the greatest long-term benefit from LVADs, because their implantation risk will be lower, and the [device's] impact on quality of life, amortized throughout the life of the LVAD, will be that much greater."

Our feeling is that engaging them early on about their own thresholds for considering an LVAD is extremely important.

One likely reason for the shortfall, he said, is that patients are unfamiliar with the technology, and little is known about their level of its acceptance. "How can LVADs be safely expanded into that group, and when do we approach such patients about their use? Our feeling is that engaging them early on about their own thresholds for considering an LVAD is extremely important," he said, "before they get so sick that the implant risk will be unacceptably high."

The public is becoming more knowledgeable about LVADs all the time, Stewart said, and in recent months there's been "a noticeable change in patients' level of comfort in the discussion." Patients are coming to him and saying, "I want one of those things that Dick Cheney has."

The former vice president recently published a controversial memoir and has become a mainstay of TV talk shows and news broadcasts, frequently discussing his epic history of heart disease and showing off the exterior power packs for the HeartMate 2 (Thoratec) LVAD he received in 2010.

The patients Stewart and his colleagues studied were in NYHA class 3 or 4 heart failure with an LVEF no higher than 30% and on evidence-based medications for at least six months. They also had at least one other high-risk feature, such as a history of at least two HF hospitalizations in the past year or one such HF hospitalization plus especially poor functional capacity. Half had been previously evaluated for possible LVAD implantation.

Distribution of Responses to Questionnaire Query, "Based on How You Feel Right Now, Would You Want an LVAD?"

Response % (n=150)
Definitely want 25
Probably want 32
Don't know 25
Probably not 12
Definitely not 7

The lower the patient's INTERMACS profile score--that is, the more advanced their disease and the worse they were functionally and clinically--the more likely they were to respond that they would definitely want an LVAD (p=0.016 for trend). A history of at least five HF hospitalizations nearly tripled the likelihood of definitely wanting an LVAD, adjusted for age, prior LVAD knowledge, Seattle Heart Failure Model prognostic score, and heart-failure etiology.

Over half said they would 'definitely' or 'probably' want an LVAD even if they had less than two years to live.

Of the cohort, about 65% said they would definitely want an LVAD if they had less than a month to live. "But over half said they would 'definitely' or 'probably' want an LVAD even if they had less than two years to live," Stewart said.

Speaking from the audience during the question-and-answer period following Stewart's presentation, Dr Stephen S Gottlieb (Maryland Heart Center at the University of Maryland, Baltimore) asked how much the patients knew about LVADs before filling out the questionnaire. It "would have been nice" if they understood what living with the devices would be like at that point, compared with living without them.

Stewart replied that the questionnaire started with a two-paragraph "standardized description of a generic LVAD," stating that it involved surgery and providing the length of the hospital stay and the potential complications. Of note, 49% of the patients had previously been evaluated for possible LVAD implantation or transplantation, so many had already heard of the devices.

Stewart and Gottlieb reported that they had no disclosures.