OPTIMIZING THE VALUE OF LEFT VENTRICULAR ASSIST DEVICE THERAPY (LVAD): RESULTS FROM A QUÉBEC FIELD EVALUATION

Abstract

The left ventricular assist device (LVAD) has become an accepted therapy for terminal heart failure in the last decade. Our publicly funded cardiovascular evaluation unit has been mandated by the Québec Ministry of Health to collaborate with clinical experts to develop patient selection criteria for LVAD. To inform the decision-making process, we examined the results of our province-wide field evaluation concerning in-hospital mortality in sub-groups of Québec LVAD patients and long-term clinical outcomes. We abstracted patient data collected by the clinical teams in Québec’s 3 centres. All LVAD patients from 2010-14 were included. All 83 patients were implanted with a Heartmate II™ device. Annual volume per centre varied from 0 to 11 while 5-year volume ranged from 21 to 38. Despite this variation, in-hospital mortality was not significantly different across the 3 centres. In-hospital mortality tended to increase with age, being 0% in patients under 40 years, 10% in ages 40-59 and 17% in patients 60 and over (p=0.2), the latter comprising 35% of LVAD recipients. Females comprised 20% and had 0% in-hospital mortality compared to 13.6% in men (p=0.2). Over the 5-year period, 13%, 36% and 40% of implanted patients were, respectively, in INTERMACS profiles 1, 2 and 3. In-hospital mortality for patients in cardiogenic shock (profile 1) was 36% vs. 10% for progressive decline (profile 2) and 3% for stable but inotrope dependent patients (profile 3; p=0.01). Nearly half (47%) were implanted as bridge-to-transplant, 33% as bridge-to-candidacy, 11% as destination therapy and 8% as rescue therapy with respective in-hospital mortalities of 18%, 0%, 0% and 29% (p=0.04). As of January 2015, after a median follow-up of 305 days, 39% had cardiac transplantation, 35% were alive on LVAD support, 19% died on LVAD support, and 7% had LVAD removal due to myocardial recovery. The Québec experience of LVAD implantation over the last 5 years shows expected increasing risk of in-hospital mortality with age and INTERMACS profile of disease severity, being highest in cardiogenic shock/rescue therapy patients. Despite relatively small and variable annual volume per centre, less than 20% of all implanted patients have died on LVAD support, suggesting the value of this costly technology in carefully selected patients. Continued independent monitoring of LVAD patients even after explant/transplant will be important to optimize the value and quality of care of end-stage heart failure.