Clinical Outcomes After Left Ventricular Assist Device Implantation in Older Adults: An INTERMACS Analysis

Cesar Caraballo; Ersilia M. DeFilippis; Shunichi Nakagawa; Neal G. Ravindra; P. Elliott Miller; Catherine Mezzacappa; Megan McCullough; Jadry Gruen; Andrew Levin; Samuel Reinhardt; Clancy Mullan; Ayyaz Ali; Mathew S. Maurer; Nihar R. Desai; Tariq Ahmad; Veli K. Topkara

doi:10.1016/j.jchf.2019.10.004

JACC: Heart Failure

Volume 7, Issue 12, December 2019 DOI: 10.1016/j.jchf.2019.10.004

Clinical Outcomes After Left Ventricular Assist Device Implantation in Older Adults
An INTERMACS Analysis

Cesar Caraballo, Ersilia M. DeFilippis, Shunichi Nakagawa, Neal G. Ravindra, P. Elliott Miller, Catherine Mezzacappa, Megan McCullough, Jadry Gruen, Andrew Levin, Samuel Reinhardt, Clancy Mullan, Ayyaz Ali, Mathew S. Maurer, Nihar R. Desai, Tariq Ahmad and Veli K. Topkara

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Author + information

vol. 7 no. 12 1069-1078

DOI:

https://doi.org/10.1016/j.jchf.2019.10.004

Published By:

JACC: Heart Failure

Print ISSN:

2213-1779

Online ISSN:

2213-1787

History:

Received August 27, 2019
Revision received October 9, 2019
Accepted October 10, 2019
Published online November 25, 2019.

2019 American College of Cardiology Foundation

Author Information

Cesar Caraballo, MD^a,^∗,
Ersilia M. DeFilippis, MD^b,^∗,
Shunichi Nakagawa, MD^c,
Neal G. Ravindra, MPhil^d,^e,
P. Elliott Miller, MD^f,
Catherine Mezzacappa, MD, MPH^g,
Megan McCullough, MD^h,
Jadry Gruen, MD^g,
Andrew Levin, MD^g,
Samuel Reinhardt, MD^f,
Clancy Mullan, MD^h,
Ayyaz Ali, MD, PhD^h,
Mathew S. Maurer, MD^b,
Nihar R. Desai, MD^a,^f,
Tariq Ahmad, MD, MPH^a,^f,^†^∗∗ (tariq.ahmad{at}yale.edu) and
Veli K. Topkara, MD, MSc^b,^†^∗ (vt2113{at}cumc.columbia.edu)

^aCenter for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
^bDivision of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
^cAdult Palliative Care, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
^dDepartment of Molecular Biophysics and Biochemistry, Yale University School of Medicine, New Haven, Connecticut
^eIntegrated Graduate Program in Physical and Engineering Biology, Yale University School of Medicine, New Haven, Connecticut
^fSection of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
^gDepartment of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
^hSection of Cardiovascular Surgery, Yale University School of Medicine, New Haven, Connecticut

↵∗Address for correspondence:
Dr. Veli K. Topkara, Center for Advanced Cardiac Care Columbia University Medical Center, New York-Presbyterian Hospital, 622 West 168th Street, PH10-203A, New York, New York 10032.
↵∗∗Dr. Tariq Ahmad, Section of Cardiovascular Medicine, Yale School of Medicine, 330 Cedar Street, New Haven, Connecticut 06510.

Central Illustration

Abstract

Objectives The purpose of this study was to examine outcomes after left ventricular assist device (LVAD) implantation in older adults (>75 years of age).

Background An aging heart failure population together with improvements in mechanical circulatory support (MCS) technology have led to increasing LVAD implantations in older adults. However, data presenting age-specific outcomes are limited.

Methods Adult patients in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) who required durable MCS between 2008 and 2017 were included. Patients were stratified by 4 age groups: <55 years of age, 55 to 64 years of age, and >75 years of age. Kaplan-Meier survival estimates were used to assess post-LVAD outcomes, with log-rank testing used to compare groups. Univariate and multivariate cox proportional hazard regression models were used to determine predictors of survival and complications.

Results A total of 20,939 individuals received an LVAD during the study period: 7,743 (37.0%) were <55 years of age, 6,755 (32.3%) were 55 to 64 years of age, 5,418 (25.9%) were 65 to 74 years of age, and 1,023 (4.9%) were ≥75 years of age or older. After multivariate adjustment, adults ≥75 years of age had increased mortality post-LVAD implantation. Elderly patients with LVADs had a higher incidence of gastrointestinal bleeding but lower rates of device thrombosis. Compared to 84.5% of patients <55 years of age who were discharged home, only 46.8% of adults ≥75 years of age were discharged home following implantation (p < 0.001). Use of a RVAD, serum albumin level, and 6-min walk test distances were identified as predictors of outcomes in the oldest cohort.

Conclusions Despite careful selection of older adults for LVAD implantation, age remains a significant predictor of mortality. Higher bleeding and lower clotting risk in elderly patients with LVADs support the use of a less intense antithrombotic regimen in this unique population.

Key Words

Footnotes

↵∗ Drs. Caraballo and DeFilippis contributed equally to this manuscript as co-first authors.
↵† Drs. Ahmad and Topkara contributed equally to this manuscript as co-senior authors.
Dr. Desai is a consultant for Amgen, Boehringer Ingelheim, Novartis, and Relypsa. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Received August 27, 2019.
Revision received October 9, 2019.
Accepted October 10, 2019.

2019 American College of Cardiology Foundation

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