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Left-ventricle assist device improves survival, quality of life

By Travis Abicht, MD, cardiothoracic surgeon, and Andrew Sauer, MD, cardiologist

Travis Abicht, MD, cardiothoracic surgeon, and Andrew Sauer, MD, cardiologistFor patients who have been hospitalized two to three times for heart failure, surviving the next year is a coin toss. Left ventricular assist devices (LVADs) can help keep this population alive and improve quality of life. Internationally, the 1-year survival rate is 80%. Ours is 92% so far, and maintaining a 90% rate is an attainable goal.

Offering LVADs and other mechanical circulatory support devices is an essential part of comprehensive care as The University of Kansas Health System enhances its advanced heart failure and transplant services. It also gives patients in the region a second opinion close by. Having more than one local institution with this capability also increases overall visibility and challenges each hospital to maintain and improve quality and outcomes.

We have built a team of professionals who have experience with LVADs as part of established, high-volume institutions. This experience, combined with surgical skill, an excellent nursing team and dedicated palliative care experts, has enabled us to get patients back on their feet and living successfully. Our length of stay averages about 18 days, much better than the national average of 24 days.

HeartMate II® and HeartWare® devices available

We use two different devices – the HeartMate II LVAD and the HeartWare HVAD®.

The HeartMate II LVAD is a surgically implanted, rotary continuous-flow system that works in parallel with the native left ventricle. It's powered electrically through a percutaneous driveline. The HeartMate II was developed with the goal of providing several years of circulatory support for a broad range of advanced heart failure patients – as a destination therapy or bridge to transplant.

The HeartWare HVAD is a newer LVAD that fits totally within the pericardium. It is a smaller, centrifugal flow device, which we can implant less invasively, through a small thoracotomy and another small incision, avoiding a full sternotomy. This procedure can shorten length of stay and decrease blood loss and right ventricular dysfunction, allowing patients to return to daily life sooner.

Each device has benefits. Both are durable, safe and able to get patients out of heart failure so they can enjoy life. We may be more likely to recommend the HeartWare HVAD for very small people and those without other cardiac issues. But we also have to balance the risks: The HeartWare HVAD has a higher stroke rate in the long term, while the HeartMate II LVAD has a higher thrombosis rate. We have had success managing both with refined surgical techniques and careful control of blood pressure and anticoagulation.

Quality of life enhanced

Some patients fear an assist device will negatively affect their quality of life. To the contrary, our experience and data prove that patients have an objective increase in quality of life when they come out of heart failure supported by a device. Most can do 90% of what they could prior to receiving the device – sometimes even more.

Additionally, we are able to do these procedures with less intervention than ever before. We are experiencing so many advances that medical assistance may one day rival transplant for longevity and outcomes.

Transplant outcomes improved

Another common fear is the device will negatively affect the outcome of a future transplant. Our experience shows that some patients who receive a VAD prior to transplant see their heart failure symptoms abate, along with improvement in kidney, liver and respiratory function. They go into the transplant stronger and have better outcomes.

When to refer

  • You are worried about the patient
  • Recurrent NYHA Class III heart failure
  • Intolerance to ACE-I/ARB/BB
  • CRT nonresponders
  • Renal function worsens with diuresis
  • NA < 135
  • Inotropes being considered or initiated
  • More than one HF admission in six months

When deciding if a patient is a good assist device candidate, we operate within a wide spectrum of parameters. For example, there's no specific ejection fraction cutoff for qualifying. Also, we don't automatically reject candidates with a smoking or drug abuse history, those with cancer or people without insurance. We try to see everyone we can. And we prefer to consult with physicians early, so we can work together with the patient to consider options.

Earlier evaluation for greater opportunities

We encourage referring physicians to consult us earlier rather than later as they manage patients' heart failure. We can work with you to complete a full heart failure evaluation. Our methodical evaluation process and access to a variety of therapies can help identify the next steps.

Coordinated care is a priority

We try to make the evaluation, surgery and follow-up care as stress free as possible for patients and referring providers. We work to maintain a constant stream of communication with providers through our nurse navigators. We are happy to provide reports as frequently as desired and to co-manage the complex VAD care as much as possible – especially for patients who live a distance from the hospital. Our VAD coordinators, advanced-practice providers and physicians are available 24/7 to address any concerns.

Dr. Abicht, surgical director of the heart transplant program at The University of Kansas Health System, is a cardiothoracic surgeon specializing in heart transplantation. He is board-certified in surgery and thoracic surgery, and also serves as surgical director of cardiac transplantation and mechanical circulatory support.

Dr. Sauer is a cardiologist at The University of Kansas Health System and medical director of our advanced heart failure and transplantation services. He is board-certified in internal medicine with subcertifications in cardiovascular diseases and advanced heart failure/transplant cardiology.