CHAPTER 1
PATIENT SELECTION, TIMING, AND INDICATIONS FOR
DURABLE LVAD IMPLANTATION
Contributors: Garrick C Stewart, Finn Gustafsson
Introduction
When selecting patients for durable left ventricular assist device (LVAD) therapy, the considerable benefits of treating advanced heart failure (HF) must be weighed against significant risks and considerable costs. There is an inherent dilemma in selecting the right patients for the right device at the right time. If patients are implanted too early, outcomes after implantation may be good, but the net benefit is small since outcomes would also have been good with ongoing medical and electrical therapy. Conversely, if the device is implanted too late, outcomes may be poor, with or without device therapy (Figure 1).
Selection of LVAD candidates: overall principles
Figure 1. Overall Principles in the Selection of LVAD Candidates. Estimates of survival with (dashed green line) or without (dashed red line) LVAD therapy can provide insight into the appropriateness of device candidacy. (Reproduced with permission Lars Lund, MD, personal communication)
Consequently, selection and timing for LVAD implant first requires accurate estimation of the patient’s prognosis in the absence of advanced therapies like LVAD or transplantation. Multiple studies describe prognostic factors in groups of patients (or in an “average” patient in that population) and may help identify relevant risk factors. However, the incremental impact of a given factor (e.g. renal dysfunction) on an individual patient within their broader risk profile is often not well understood. Studies addressing an individual patient’s prognosis with HF are less prevalent and often come with their own limitations. The selection of the optimal candidate for LVAD therapy must begin with the identification of patients on high risk heart failure trajectories who may be a candidate for an evaluation for mechanical circulatory support (MCS).
Clinical Presentation
Hospitalization for acute decompensated HF (ADHF) is an extremely important marker of risk, as it identifies a highly vulnerable period in the patient’s journey with HF. Data from the United States reveal that mortality is 3-4 % in-hospital during an admission with HF, 10-12 % at 30 days following discharge, and 30-40 % after one year1. Rehospitalization rates are high and generally reported to be 45-65% within the first year1,2. Among patients with ADHF, the manner of clinical presentation may further identify patients at high risk. At one end of the spectrum, patients admitted with cardiogenic shock after myocardial infarction (MI) have a 30-day mortality greater than 40%3. In patient
