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

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

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).

(Enlarge Image)

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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Table 1. Semistructured Script for Pre-VAD Evaluation
Pre-VAD evaluation
1. Patient comfort
2. Patient and family understanding of LVAD therapy a. When did you hear about LVAD? b. How did you feel about LVAD as your treatment option? c. Is that BTT or DT?
3. Patient goals and expectations a. What makes your life meaningful? What is your quality of life? b. What are you hoping to achieve by getting a VAD? What are things you look forward to doing after getting your VAD?
4. Spiritual needs (FICA tool) a. Are you a spiritual person? Are you religious? b. How important is it? c. What role do your beliefs play in regaining your health? Are you part of a spiritual or religious community? d. How would you like your healthcare provider to address these issues in your healthcare?
5. Possible complications and exploration of unacceptable conditions? a. Having an LVAD can cause its own problems, such as stroke or infection. What if things do not go well? b. These complications can cause significant disability and keep you from achieving your goals. c. What are the conditions you would find unacceptable? d. Debilitative comorbid conditions (not associated with an LVAD). Rather, caused because an LVAD prolongs survival. e. Having an LVAD as DT means that you are going to live with that pump for the rest of your life. The better you do with an LVAD, the more possibility you are going to have problems, such as cancer or dementia. They can become greater issues than heart failure. f. Are you aware that you can turn off LVAD at any future point if it no longer meets your goals of care?
6. Discussion-making and information-sharing preferences a. Who is your healthcare agent? Have you discussed the above with that person?

Abbreviations: BTT, bridge to transplant; DT, destination therapy; LVAD, left ventricular assist device.

Table 2. Complications of LVAD Therapy
Complication	Frequency reported in select studies	Average age of patients studied	Data among olderadults aged >75 y	Reported impact of age on complication
Stroke^a	Ischemic strokes: 5.65%⁷¹ Hemorrhagic stroke: 5.55%	33.5% were aged 60–69 y	Not specifically reported	Higher incidence of strokes in patients aged >60 y⁷²
GI bleeding^b	30% of patients with HeartMate II as DT experienced major GI bleeding⁷³	Aged 56 y	Not specifically reported	Patients aged >66 y have twice the risk of bleeding with continuous-flow LVAD (65% in adults aged >66 y)
RHFc	31% of patients with RHF had severe RV failure, which was associated with significantly higher mortality⁷⁴	Aged 57 y	Not specifically reported	Unknown
Device infection	3 mo after implant, 29% of patients with driveline infections in ISHLT registry⁷⁵	No average age reported; 60% aged between 50–69 y; 12.2% aged ≥70 y⁷⁵	Not specifically reported	Younger age has been reported to be associated with higher risk of device infection In one study of VAD patients aged >60 y, 22% had LVAD-related infection⁷⁶
Declining neurocognitive function^d	Cognitive decline occurred in 29.2% of LVAD patients 1 year postimplantation in INTERMACS and in the study by Fendler et al⁷⁷	No average age, 34% between 60–69 y	Associated with older age	Hazard ratio of 2.24 for cognitive decline after LVAD implant in patients aged ≥70 y
AI^e	Significant AI is associated with higher rates of rehospitalization and mortality	No average age reported, 44.6% aged >60 y	Not specifically reported	Older age is a predictor for worsening AI following LVAD implantation⁷⁸

Abbreviations: AI, aortic insufficiency; DT, destination therapy; GI, gastrointestinal; INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Support; ISHLT, International Society for Heart and Lung Transplantation; LVAD, left ventricular assist device; RHF, right heart failure; RV, right ventricular.
^aIschemic stroke was defined as a new acute neurologic deficit of any duration associated with acute infarction on imaging corresponding anatomically to the clinical deficit. Acute symptomatic intracranial hemorrhage is defined as new acute neurologic deficit (or acute encephalopathy or seizures in children aged <6 months) attributable to intracranial hemorrhage.
^bMajor gastrointestinal bleeding was defined as requiring transfusion greater than 7 days after implantation.
^cRHF was defined as signs and symptoms of persistent RV dysfunction and stratified by duration of inotrope requirement (mild, <7 days; moderate, 8–14 days; severe, >14 days; or severe acute, needing RV assist device implantation).
^dDeclining neurocognitive function defined using Trail Making B Test.
^eAI was defined on echocardiography as none, mild, moderate, or severe.

Table 3. Basic Principles of Geriatrics as Applied to Older Adults Being Considered for or Getting an LVAD
Principles	Application to older adult candidates or recipients of LVADs
Chronologic age should not be considered in isolation for LVAD candidacy.	Since aging occurs at different rates among individuals and within an individual in different organ systems, assessment of biologic aging using physiologic measures of organ function, nutrition, physical function (eg, frailty), and cognitive function is essential to assess candidacy for LVADs in older adults.
Multimorbidity is common in older adults, especially among those with advanced heart failure.	In older adults with advanced heart failure, the presence of multiple chronic conditions complicates decision making for LVAD candidacy and often is a critical factor in LVAD candidacy and makes management of older adults on LVADs complex and challenging.
Functional ability and quality of life are critical outcomes in the older adult population receiving an LVAD.	Functional capacity after LVAD is a main determinant of independence in older adults and is a critical rationale for pursuing LVAD therapy. This may conflict with the need for strong social supports and reliance on caregivers for post-VAD management.
Personal history, social support, and patient preferences are essential aspects of managing older adults on LVADs.	Elucidating a patient's life history and preferences for care are critical to appropriate management of LVADs, especially in the face of post-LVAD complications. Caregiver support and living circumstances as well as available resources are critical to effectively managing older adults receiving an LVAD.
Care of older adult patients on LVADs is multidisciplinary.	Multiple disciplines, including but not limited to cardiology, especially advanced heart failure providers, cardiac surgeons, nurse practitioners, palliative care experts, occupational and physical therapists, geriatricians, dieticians, nurses, pharmacists, social workers, and subspecialists (eg, in gastroenterology, hematology, or neurology), are required to care for older adults on LVADs.
Cognitive dysfunction, sensory disturbances, and affective disorders are common but often overlooked in assessing candidacy for LVAD.	Aging is associated with changes in cognitive function and limitations in fine motor function as well as hearing and vision disturbances that can negatively affect outcomes after an LVAD. Screening for delirium, dementia, and depression should be routinely done; and further testing should be dictated by initial findings.
Iatrogenic illnesses are not eliminated by LVADs and remain a preventable cause of adverse outcomes.	After an LVAD, polypharmacy is common; and adverse drug reactions, drug-disease interactions, drug-drug interactions, and unnecessary medications remain a target for deprescribing. Hospitalization after a VAD is common and places patients at risk for falls, immobility, and deconditioning, which can be serious and life threatening.
Care of older adults on an LVAD is provided in a variety of settings.	Care transitions between home, hospitals, and rehabilitation facility are common and complicated by the lack of expertise in the care of LVAD patients in many of these venues. Integrated, VAD-friendly systems are needed to ensure coordination of care for complex older adults with an LVAD.
Palliative care is an essential component of care of older adults on an LVAD.	LVADs have created new ethical issues surrounding the management of end of life. Engagement of palliative care providers throughout the care of patients on LVADs is a requisite for providing high-quality care.

Note: Adapted from the big 10 principles of geriatrics at https://medicine.emory.edu/geriatrics-gerontology/education/big-10.html.
Abbreviation: LVAD, left ventricular assist device.

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Left Ventricular Assist Device Therapy in Older Adults

Addressing Common Clinical Questions

Abstract and Introduction

Abstract

Introduction

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

Supplementary Figure S1.

Supplementary Figure S1.

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