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ORIGINAL ARTICLE  CARDIAC SECTION 

The Journal of Cardiovascular Surgery 2019 April;60(2):251-8

DOI: 10.23736/S0021-9509.18.10593-3

Copyright © 2018 EDIZIONI MINERVA MEDICA

language: English

Which advanced heart failure therapy strategy is optimal for patients over 60 years old?

Yan K. GERNHOFER 1 , Oscar O. BRAUN 2, Michela BRAMBATTI 3, Quan M. BUI 3, Jorge SILVA ENCISO 3, Barry H. GREENBERG 3, Eric ADLER 3, Victor PRETORIUS 1

1 Division of Cardiothoracic Surgery, Department of Surgery, University of California San Diego, Sulpizio Cardiovascular Center, La Jolla, CA, USA; 2 Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden; 3 Department of Cardiology, University of California San Diego, Sulpizio Cardiovascular Center, La Jolla, CA, USA



BACKGROUND: The optimal advanced heart failure (HF) therapy strategy for patients aged 60 or older with end-stage HF refractory to optimal medical therapy remains uncertain. This study compares outcomes of three advanced HF therapy strategies in this patient population.
METHODS: A single-center retrospective study was conducted in 95 patients aged 60-73 years who had undergone isolated heart transplantation (HTx) or continuous flow left ventricular assist device (LVAD) implantation from 2010 to 2017. Patients were stratified into three cohorts by strategy; HTx-only (N.=25), LVAD-to-HTx (N.=29), and LVAD-only (N.=41). Primary end point was 2-year overall survival. Secondary end points included incidence of post-operative adverse events, freedom from first readmission at 1 year, and percentage of days spent in hospital following advanced HF therapy.
RESULTS: Two-year survival was 91% in HTx-only patients, 88% in LVAD-to-HTx patients, and 49% in LVAD-only patients (P=0.0008). No significant difference in post-transplant survival was found between patients with or without LVAD-related adverse events preceding transplantation (P=0.42). One-year freedom from first readmission was 38.3% in HTx-only patients, 17.2% in LVAD-to-HTx patients and 7.3% in LVAD-only patients (P=0.0028). Patients in LVAD-to-HTx cohort had higher incidences of gastrointestinal bleeding (38% vs. 3%; P<0.01), major bleeding (28% vs. 3%; P=0.02), and right heart failure (69% vs. 31%; P<0.01) during post-LVAD period compared with post-HTx period. Their percentage of days spent in hospital during post-LVAD period was significantly higher than post-HTx period (7.9% vs. 1.2%; P<0.001).
CONCLUSIONS: Our experience with patients over 60 years old undergoing advanced therapy suggests that HTx-only and LVAD-to-HTx strategies had superior medium-term survival than LVAD-only strategy. LVAD-to-HTx strategy is effective in reducing incidence of adverse events and percentage of hospitalized days in this specific patient population.


KEY WORDS: Heart failure - Left ventricular dysfunction - Heart-assist device - Heart transplantation - Aged

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