Invited Commentary

Abstract

The introduction of continuous-flow left ventricular assist devices (LVADs) has had a major impact on the beneficial outcomes and acceptance of this therapy for patients with advanced heart failure. These long-term LVADs are typically implanted for three primary indications: bridge to transplant, bridge to recovery, and destination therapy, in addition to bridge to decision in patients who may become candidates for transplantation after a period of mechanical circulatory support (MCS). The REMATCH trial [1Rose E.A. Gelijns A.C. Moskowitz A.J. et al.Long-term mechanical left ventricular assistance for end-stage heart failure.N Engl J Med. 2001; 345: 1435-1443Crossref PubMed Scopus (3368) Google Scholar] was a landmark study demonstrating a significant 1-year and 2-year survival benefit of the pulsatile, first generation, HeartMate XVE LVAD versus optimal medical therapy in a cohort of patients with advanced heart failure who were ineligible for transplantation. Current studies with continuous-flow LVADs show 1-year survival rates of approximately 85% [2Starling R.C. Naka Y. Boyle A.J. et al.Results of the post-U.S. food and drug administration-approval study with a continuous flow left ventricular assist device as a bridge to heart transplantation: a prospective study using the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support).J Am Coll Cardiol. 2011; 10 (57): 1890-1898Abstract Full Text Full Text PDF Scopus (373) Google Scholar]. Given this dramatic improvement in patient survival, a current emphasis in the field of long-term MCS is preventing complications associated with these devices and maximizing quality of life. This study from Forest and coauthors comprehensively evaluates their readmissions after LVAD implantation in the current era of MCS [3Forest S.J. Bello R. Friedmann P. et al.Readmissions after ventricular assist device: etiologies, patterns, and days out of hospital.Ann Thorac Surg. 2013; 95: 1276-1281Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar]. The study population included 71 adult patients who underwent continuous-flow LVAD implantation at their institution with either the Thoratec HeartMate II (n = 58), the Heartware HVAD (n = 9), or the Ventrassist VAD (n = 4). The overall benefit of this therapy was highlighted by their finding that, on average, LVAD patients spent 92% of their time out of the hospital. The majority of this time was at home. However, 56 patients were readmitted during the mean follow-up period (359 days), with the median time to first admission being 48 days. The most common cause of admission after implantation of the LVAD was gastrointestinal bleeding, which accounted for 14% of readmissions. Only 3% of all readmissions were life-threatening. Other reasons for readmission included LVAD-related and non–LVAD-related infections, volume overload, arrhythmias, stroke/transient ischemic attack, syncope, and elective desensitization. At the end of the study period, 85% of patients were alive and were receiving ongoing LVAD support (35%), had undergone transplantation (46%), or had undergone device explantation for recovery (4%). The development of new strategies to minimize postimplantation complications and reduce readmissions is critical for the expansion of LVAD technology by optimizing the long-term survival, quality of life, and cost-effectiveness of this therapy. Readmissions After Ventricular Assist Device: Etiologies, Patterns, and Days Out of HospitalThe Annals of Thoracic SurgeryVol. 95Issue 4PreviewScarce literature exists describing the patterns of readmission after continuous flow left ventricular assist device (CF-LVAD) implantation. These carry significant cost and quality of life implications. We sought to describe the etiology and pattern of readmission among patients receiving CF-LVADs. Full-Text PDF