Frailty and the Selection of Patients for Destination Therapy Left Ventricular Assist Device

Abstract

Frailty is the aggregation of subclinical physiological insults across many organ systems resulting in a syndrome of heightened vulnerability in the face of stress. Measures of frailty are highly predictive of adverse outcomes in many medical and surgical populations but have never been formally applied to patient selection for destination therapy left ventricular assist device (LVAD). Patients with severe heart failure being considered for destination therapy LVAD often have advanced age or noncardiac morbidity that renders them ineligible for transplantation. At the same time, these patients should have reasonable life expectancy to adequately realize the benefits of LVAD. As such, destination therapy LVAD-eligible patients are in a precariously narrow state of health often marked by a high degree of frailty. However, distinguishing frailty that will reverse with LVAD therapy (LVAD-responsive frailty) from frailty that will not (LVAD-independent frailty) is challenging. In this review, we summarize existing tools for destination therapy LVAD patient selection, define the syndrome of frailty, propose a conceptual distinction between LVAD-responsive frailty and LVAD-independent frailty, extrapolate the existing frailty literature to destination therapy LVAD-eligible patients, and identify directions for future research, including systematic collection of preoperative gait speed in this patient population.