Editorial Comment: Multimodal intervention in the management of left ventricular assist device outpatients

Abstract

A masterpiece of marine engineering, the Titanic hits an iceberg and sank on it’s maiden voyage 100 years ago (April 1912), with the loss of 1500 lives. Peter Houghton was the first person to receive a rotary blood pump for destination therapy in 2000. He lived an active and productive life for 7.5 years and died from a non-cardiac event [1]. Peter’s key to LVAD longevity was a positive attitude. Rejected for cardiac transplantation at the age of 58, he spent 10% of his overall life span supported by batterypowered technology and worked tirelessly in an attempt to give others the same opportunity. Chronic heart failure patients become accustomed to a sedentary life with poor exercise tolerance and limited independence. Those with idiopathic dilated cardiomyopathy tend to become cachectic and wasted. In contrast, ischaemic cardiomyopathy patients are frequently diabetic, hypertensive, overweight or frankly obese, with metabolic syndrome [2]. Neither category recovers rapidly after major surgery, and it takes weeks for an LVAD to reverse the neurohormonal ravages of a severe heart failure. Lietz et al. [3] showed both pretransplant cachexia and morbid obesity to be predictors of the poor outcome after a cardiac transplantation. Detailed medical management and dedicated family support are widely recognized as essential for the LVAD patient, but surprisingly, rehabilitation programmes have not featured in the circulatory support literature. In this journal, Kugler et al. [4] from Hannover report the first formal prospective clinical trial whereby active supportive measures in the form of nutritional guidance, an exercise regime and psychosocial support were provided for one group of LVAD patients, while controls received the conventional LVAD follow-up. Patients were consecutively allocated rather than randomized and received a HeartMate II or HeartWare LVAD as a bridge to cardiac transplantation. A detailed pre-LVAD patient characteristics are not presented in this manuscript, but some were also included in the multicentre evaluation of the HeartWare LVAD report, and were INTERMACS profile 2–4 (predominantly 3) with cardiac index <2 l/min/m [5]. Half were on intropic support. As transplant candidates, the patients were young (median 52) and predominantly male (86%), with dilated cardiomyopathy more frequently than ischaemic cardiomyopathy. As might be expected, the study outcomes showed benefit for the actively managed group who did not increase their body mass index (BMI) and achieved better exercise tolerance over time. It took virtually the full 18-month follow-up period to achieve a statistical significance between the groups. The physical benefits were reflected by a significant improvement in the health-related quality of life score together with less anxiety over time but only in the actively treated patients [4]. The recently reported HeartWare LVAD multicentre bridge to transplant study used the Kansas City Cardiomyopathy Questionnaire to evaluate improvements in symptomatic burden, quality of life, physical limitations and overall functional status [5]. This study showed progressive improvements in each domain that proved statistically significant for each of the 1-month, 3-month and 6-month follow-up periods. The greatest improvement occurred within the first 30 days. A significant benefit was found in neurocognitive function after 3 months compared with pre-LVAD values. From the Hannover study, it would have been useful to know whether the incremental benefit from nutritional, exercise and psychological rehabilitation translated into improved transplant outcomes. Kilic et al. [6] reviewed data from 15 960 patients included in the United Network for Organ Sharing (UNOS) Registry who received cardiac transplants between 1998 and 2008 to determine the influence of metabolic risk factors on survival. They specifically examined obesity, diabetes mellitus and hypertension individually and in combination. Pre-operative hypertension was found in 40%, obesity in 25% and 21% were diabetic. Only 40% had none of the three, while 18% had two and 4% all three risk factors. Those with all three were older (mean 55 vs 50 years), more likely to be male and had significantly higher serum creatinine. Predictably, they were more likely to have ischaemic