The Left Ventricular Assist Device: Can It Have an Impact on Quality of Life for Patients With End- Stage Heart Failure?

Offering a closer look at the evolution of left ventricular assist devices (LVADs), this author discusses key indications, common risks with the procedure, and pertinent post-op steps for improving outcomes. By Barbara Zeiger

Patients with heart failure (HF) have a greater than 50 percent mortality rate. Five percent of these patients have end-stage or advanced heart failure. They are Class IV according to the New York Heart Association (NYHA) classification. These patients are unable to carry on any physical activity without discomfort, and they are tired and short of breath even while resting. It is important that these patients get specialized interventions.

Some HF patients can benefit from a left ventricular assist device (LVAD). The LVAD can be utilized to help increase the heart’s capacity to pump oxygen-rich blood, allowing people to be at home or work and live a more active, full life. Patients whose medications are not working and in whom transplant is not feasible can receive an LVAD for the long-term. The LVAD also may be used to support patients with HF who are awaiting transplant as a short-term bridge therapy, giving the heart and vital organs time to rest and gain strength until transplant surgery can be per- formed. In either case, LVADs have been proven to reverse the symptoms of heart failure, improve a patient’s quality of life, and help patients live longer.

How an LVAD Works

The LVAD is implanted by a cardiothoracic surgeon during a four- to six-hour open-heart surgery. The LVAD pump, placed in the chest, helps support the left ventricle’s pumping function. The driveline is attached to the pump and

it goes through the abdominal wall to the outside of the body. The driveline sends information to the controller and receives power from the batteries to keep the pump running at all times. Since the driveline goes through the skin, it’s important to keep the exit site clean to facilitate healing and avoid infection.

A controller will alarm to alert the wearer when the LVAD battery needs changing. The pair of batteries provide up to 17 hours of uninterrupted power. Most patients wear their external controller and batteries in a shoulder bag, backpack, or a belt/harness.

Are All LVADs the Same?

Two types of chronic LVADs have been approved by the Unites States Food and Drug Administration: an axial flow pump called the HeartMate II Left Ventricular Assist Device (Abbott Laboratories), and a centrifugal flow pump called Heart- Mate 3 Left Ventricular Assist System (Abbott Laboratories). HeartMate 3 is the most widely used LVAD and has been implanted in over 20,000 patients throughout the world. There are a few newer LVADs being studied now but they have not yet received approval.

Who is Eligible for an LVAD?

The HeartMate 3 Left Ventricular Assist System is indicated for providing short- and long-term mechanical circulatory support (e.g., as bridge to transplant or myocardial recovery, or destination therapy) in adult and pediatric patients with advanced refractory left ventricular heart failure and an appropriate body surface area. Physicians will evaluate the patient’s ejection fraction with normal ranging between 50 to 70 percent. Contraindications for LVAD include those who cannot tolerate, or who are allergic to, anticoagulation therapy. Patients who are living with an LVAD will need to make adjustments to their lifestyle and need to be responsible to care for themselves, their batteries, their driveline site, and manage their controller. For this reason, patients often need a strong social and/or caregiver support network to help them.

Risks and Consequences

There are risks with any surgical procedure, and open-heart surgery is particularly complex. LVADs have been associated with pump thrombosis, bleeding, cerebrovascular (CVA) event, infection, and right ventricular failure.

Infection. Clinical studies have shown that major infection can occur in up to 42 percent of patients. Driveline infections were the most common, the easiest to treat, and resulted in fewer long-term issues. Younger age and higher body
mass were associated with greater risk for infection. Infections of the bloodstream were associated with CVA and higher mortality.

Adaptation. The emotional and physical changes of having an LVAD cannot be overlooked, and adaptation to the device takes time. Patients are not entirely independent of care and complications can compromise quality of life for both the patient and caregiver. As such, patients should talk with their doctors and care- fully consider the best choice for them.

Keys to Success with LVAD Use

Patrick J. McCann, MD, the director of Heart Failure and Mechanical Circulatory Support at Prisma Health Heart Hospital in Columbia, SC, says LVAD use is a quickly growing therapy, owing to the increase in HF patients, especially over the past decade. He notes that his center has implanted approximately 200 LVADs.

To ensure maximum outcomes from LVAD use, Dr. McCann recommends having backup components (batteries and controller) available should the implanted device become compromised, maintain- ing good hygiene around the driveline exit site, and ensuring that patients have a positive attitude regarding LVAD placement.

“Holistic care is important,” notes Dr. McCann “Patients should not drink or smoke, they should take their medications as prescribed, and be able to embrace both the restrictions and the improvements in their lives that a LVAD offers.”

Dr. McCann also emphasizes the need for close patient monitoring. “Unlike other heart devices, LVAD monitoring is not remote,” says Dr. McCann. “The device is interrogated during physician appointments. We think that because patients with an LVAD at our institution are monitored more closely than other HF patients via appointments every 2 to 3 months, mortality rates are lower in our LVAD recipients.”

In Conclusion

According to 2015–2018 data from the American Heart Association and the Centers for Disease Control and Prevention, more than 6 million people in the U.S. have HF. Randomized, clinical trials have shown LVAD survival rates of 79 percent and 81.2 percent at two years with the HeartMate 3 device. These results are consistent with the INTER- MACS Registry, which is a real-world database maintained by the Society of Thoracic Surgeons (STS). That registry showed a 79 percent survival rate at two years with the HeartMate 3 device. These survival rates are similar to those of heart transplant at 2 years, making LVAD therapy a viable alternative to a trans- plant. When there is appropriate patient selection and close monitoring, LVAD implantation may prolong and improve the quality of the patient’s life.