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Patients with LVADs at risk for cognitive decline, poor outcomes
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Patients with HF implanted with a left ventricular assist device are at risk for cognitive decline and poor global outcomes, according to two studies published in Circulation: Cardiovascular Quality and Outcomes.
“LVADs represent an important and beneficial therapy that patients should have the option of pursuing, though these patients should be appropriately informed regarding life with LVAD support in order to make individual decisions,” Timothy J. Fendler, MD, research fellow at St. Luke’s Mid America Heart Institute, Kansas City, Missouri, said in a press release.
Timothy J. Fendler
LVADs and cognitive decline
In one study, Fendler and colleagues described the incidence and predictors of cognitive decline after LVAD. Complications from LVAD therapy such as stroke and subclinical cerebral ischemia may manifest as cognitive decline, according to the study background.
As part of the INTERMACS registry, cognitive function is assessed before LVAD implantation and at each follow-up with the Trailmarking B Test. Fendler and colleagues examined the association between patient characteristics and cognitive decline after LVAD implantation in 1,151 patients (median age, 60 to 69 years; 19% women). At implant, 40% of patients were INTERMACS profile 1 or 2, indicating cardiogenic shock or declining despite inotropes.
Median Trailmarking B Test score improved from 126 at baseline to 123 at 1 year, but 29% of patients had significant cognitive decline within 1 year of LVAD placement.
Increasing age (OR for age 70 years or older = 3.94; 95% CI, 2.35-6.63), chronic renal disease (OR = 1.48; 95% CI, 1.04-2.1), better baseline Trailmarking B Test score per 5-second decrease (OR = 1.07; 95% CI, 1.05-1.09) and INTERMACS profile of 3 or less (OR = 1.44; 95% CI, 1.07-1.94) were associated with greater odds of cognitive decline.
“These results should help clinicians in assessing patients’ prognoses and educating potential LVAD candidates, based on risk for this important poor outcome that has not been previously well-described,” Fendler said in the release.
LVADs and global outcomes
In the other study, Fendler and colleagues analyzed patients receiving an LVAD at a single center between January 2012 and October 2013 (n = 164; mean age, 56 years; 76.7% white; 20.9% women; 85.9% INTERMACS profile 1 or 2). The primary outcome was poor global outcome at 1 year after LVAD implantation, defined as death, disabling stroke precluding transplant, poor patient-reported health status or recurrent HF (defined as two or more readmissions for HF after implant).
At 1 year, poor global outcome occurred in 35.4% of patients. Of those, 63.8% died; 29.3% had poor patient-reported health status, defined as most recent Kansas City Cardiomyopathy Questionnaire score of less than 45; 5.2% had at least two readmissions for HF and 1.7% had a disabling stroke. Eight patients who died experienced one of the other poor outcomes before death.
Compared with patients with good global outcomes, patients with poor global outcomes were more likely to be designated for destination therapy than bridge to transplant (46.4% vs. 23.6%; P = .01), have a longer median index admission (39 days [interquartile range, 24-57] vs. 25 days [interquartile range, 18-35]; P = .003) and have major gastrointestinal bleeding (44.2% vs. 27.7%; P = .056) and less likely to undergo LVAD exchange (0% vs. 12.3%; P = .004), according to the researchers.
“These studies are important, because although LVAD therapy is a powerful, life-prolonging option that frequently improves [HF-related] quality of life in very sick end-stage [HF] patients, they may also be at risk of experiencing device-related complications that could impair their overall quality of life,” Fendler said in the release. “While a third of the patients with LVAD therapy experienced a poor outcome using our definition, the likelihood of death within 1 year had these patients not received an LVAD is much higher.”
This abstract was originally prepared for presentation at the American Heart Association’s Quality of Care and Outcomes Research Scientific Sessions, which was cancelled due to protests and an ongoing state of emergency in Baltimore. – by Erik Swain
Disclosure: Fendler reports no relevant financial disclosures.
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