Left Ventricular Assist Device Therapy in Older Adults

Addressing Common Clinical Questions

Ersilia M. DeFilippis, MD; Shunichi Nakagawa, MD; Mathew S. Maurer, MD; Veli K. Topkara, MD, MSc

Disclosures

J Am Geriatr Soc. 2019;67(9):2410-2419. 

In This Article

Abstract and Introduction

Abstract

Objectives: To review the literature and summarize the evidence for left ventricular assist device (LVAD) use in older adults (aged >75 years), highlighting patient selection, day-to-day life with an LVAD, age-specific complications, and end-of-life considerations.

Design: Contemporary review of current literature on LVAD therapy in older adults.

Results: There is a paucity of data on LVAD use and outcomes in adults older than 75 years and even less commonly are such devices implanted in those older than 80 years. Candidates and recipients of this age often have multiple chronic conditions and extracardiac impairments, which can negatively affect their short-term outcomes and daily experience following LVAD implantation. Therefore, selection prior to implant should incorporate end-organ function, nutritional status, measures of frailty, neurocognitive status, and social support, among others, to determine the patient population most likely to benefit from such therapy.

Conclusion: When LVAD therapy is utilized in an older adult, the needs for multidisciplinary team management and expertise in palliative care are essential. More age-specific outcome data are required to help inform providers, patients, and caregivers.

Introduction

Improvements in heart failure (HF) therapies, coupled with an aging population, have led to an increase in the prevalence of advanced HF (AHF) in older adults. Of patients hospitalized with HF, 80% are older than 65 years. By 2030, there are projected to be 2 million Americans with HF older than 80 years.[1] In one population study of HF of over 6000 patients aged between 67 and 91 years, 13% had stage C HF.[2] Therefore, it is anticipated that an increasing number of geriatric patients will be considered for left ventricular assist device (LVAD) support in the near future.[3] LVADs are increasingly being used as "destination therapy" for AHF patients who are not eligible for cardiac transplantation. These factors, together with improvements in mechanical circulatory support technology, have led to an increase in the mean age of individuals undergoing LVAD implantation, which still remains younger than 65 years.[4] According to data from the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support), between 2006 and 2012, 5029 patients received an LVAD. Of these, 565 (11%) were aged 70 to 79 years and only 25 (0.5%) were aged 80 years or older.[5] One analysis from the Nationwide Inpatient Sample showed that LVAD implants in patients older than 75 years increased from 3.5% in 2003 to 10.5% in 2014.[6] At our institution, the percentage of LVAD implants among individuals aged 75 years or older only accounts for a small percentage of overall implants and has remained relatively stable over time (Supplementary Figure S1A). However, nationwide, there is an increase in age at implant over time (Supplementary Figure S1B), but the mean age of patients receiving an LVAD is well below the mean age of patients with HF in the United States (aged 77 years).

Supplementary Figure S1.

Trends in the use of left ventricular assist devices (LVADs) by age at implant by year at our institution (A) and in the nationwide INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) (B).

As people with AHF age, they also have significant comorbidity and functional limitations that are associated with higher risk of death and hospitalization.[7] One epidemiologic study found that of nearly 1400 HF patients, 86% had two or more chronic conditions; and these patterns were similar in both patients with preserved and reduced ejection fraction.[7] Therefore, selection of older adults for LVAD therapy requires assessment of frailty, end-organ function, nutritional status, social support, and neurocognitive function. Furthermore, as more LVAD patients exist in the community, providers of various backgrounds will be increasingly engaged in their clinical care and, thus, should be knowledgeable about the potential benefits and challenges of this therapy.[8] In this review, we will pose and address common questions and considerations regarding LVAD use in older adults.

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