Prognostic Value Of Frailty For Heart Failure Patients Undergoing Left Ventricular Assist Device Implantation: A Systematic Review

Abstract

<h3>Introduction</h3> Although frailty has been demonstrated to be a predictor of adverse clinical outcomes, its prognostic implication for patients undergoing left ventricular assist device (LVAD) implantation is complicated by the various methods for defining frailty. We therefore sought to conduct a systematic review to evaluate current frailty assessment strategies and their significance for patients undergoing LVAD implantation. <h3>Methods</h3> A comprehensive electronic search of PubMed, Embase, and CINAHL databases from inception until April 2021, as well as a review of meeting proceedings were performed in accordance with PRISMA guidelines. Studies were included if they investigated the prognostic value of frailty on clinical outcomes in advanced heart failure patients undergoing LVAD implantation (Fig. 1). Study characteristics, patient demographics, and type of frailty measurement were extracted. Primary outcomes of interest included all-cause mortality and implant length of stay (iLOS). <h3>Results</h3> Of the 260 records retrieved, 23 studies (12 retrospective, 11 prospective) involving 4935 patients (80.2% male; mean age: 58.4 years; mean follow-up: 14.2 months) satisfied the inclusion criteria. Approaches to measuring frailty and their respective degrees of subjectivity varied greatly across studies, with the two most common methods being sarcopenia determined by computed tomography (n = 9; 39.1%), and Fried's frailty phenotype assessment (n = 8; 34.8%). Sarcopenia was further subcategorized as the evaluation of pectoralis muscle index and tissue attenuation (n = 5; 21.7%), psoas muscle index (n = 3; 13%), or abdominal skeletal muscle index (n = 1; 4.3%). Other frailty measurements included handgrip strength (n = 2; 8.7%), cachexia (n = 1; 4.3%), prognostic nutritional index (n = 1; 4.3%), provider-assessed frailty (n = 1; 4.3%), and a 31-component deficit index (n = 1; 4.3%). However, regardless of the frailty measurement utilized, patients classified as frail had significantly increased all-cause mortality and prolonged iLOS compared to their non-frail counterparts. Longer time to extubation, increased rehospitalization rates, and a higher burden of adverse events during follow-up were also associated with frailty. <h3>Conclusions</h3> Frailty, by any objective metric, is a valuable prognostic indicator for increased mortality, prolonged iLOS and adverse clinical outcomes in advanced heart failure patients undergoing LVAD implantation. Determining the most sensitive markers for these poor outcomes, and how they may be used in combination, may refine assessment of this potentially modifiable risk factor for VAD implantation.