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Is 70 Years Too Old For a VAD ?
Medtronic: Consultant, Advisor and Proctor
Disclosure
Introduction• The number of patients with advanced heart failure is
increasing due to overall extended life expectancy• VAD therapy has become standard therapy for selected
patients with advanced heart failure• Short and longer term outcomes are improving • The present profile of adverse events is the main
concern of a more widespread use of LVAD therapy• Additional concern centers around the amount of
resources and cost effectiveness of LVAD therapy• It is unclear whether this should encourage the
application of LVAD therapy in patients over 70 yrs of age
Short Answer?
“ No”
Present Situation of Advanced Heart Failure in the UK
• 900000 Patients suffering from Heart Failure
• Survival worse than for Breast and for Prostate Cancer
• Mortality in most advanced Stage 70%• High Risk of Sudden Death• Prolonged Depressive Illness (1/3)• Very poor Quality of Life• 625 Mill GBP/year• 90% of HF Admissions are Emergencies• 5% of all Emergency Admissions have HF
coded as primary Diagnosis
Future Development of the Heart Failure PopulationIncrease in Ageing Population
Improved Survival in Cardiovascular DiseasesImprovement of Survival of Heart Attacks leads to Increase in
Heart Failure
What happensto the majority of patients ?
????????????
Present Situation of Advanced Heart Failure in the UK
• 900000 Patients suffering fromHeart Failure
• Survival worse than for Breast and forProstate Cancer
• Mortality in most advanced Stage 70%• High Risk of Sudden Death• Prolonged Depressive Illness (1/3)• Very poor Quality of Life• 625 Mill GBP/year• 90% of HF Admissions are Emergencies• 5% of all Emergency Admissions have HF
coded as primary Diagnosis
Too Old for a VAD ?
• The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief
• Access to NHS services is based on clinical need, not an individual’s ability to pay
• The NHS aspires to the highest standards of excellence and professionalism
• NHS services must reflect the needs and preferences of patients, their families and their carers
• The NHS works across organisational boundaries and in partnership with other organisations in the interest of patients, local communities and the wider population
Challenges
• Cerebro-vascular disease• Renal insufficiency• COPD• Frailty• Psycho-social support• Poor RV function
Today’s Options in End-Stage HF
CHF
Transplant
TransplantLVAS
LVAS
LVAS Recovery & Weaning
LVAS Cell Therapy Wean
Jarvik 7 TAH – 1985
Evolution of Circulatory Support
♥Total patient rehabilitation♥Discharged or home based♥Portable or wearable controller♥Long term support (months/years)♥Transplant when available or ready♥Selection based on multiple variables
(New Goals)
Future Trends for Rotary Blood Pumps
Technical Objectives:
•Small Size / Low Weight• Long Term Durability• Pulsatility option• Efficient Washout Out• Low power consumption• Adaptive Control (Patient Need)• Transcutaneous Energy Transfer
General Objectives:
• Minimal Surgical Trauma• Long Term Use• Easy Handling• Exchangeability• Safety and Reliability• Patient mobility/ Home Support• Cost reduction
World’s smallest heart pump fitted to British man Father-of-three has become the first person in the world to be fitted with a miniature heart pump
R2 =
0
10
20
30
40
50
60
70
80
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
Don
or A
ge (Y
ears
)
Recipient Age (Years)
2017JHLT. 2017 Oct; 36(10): 1037-1079
Adult and Pediatric Heart TransplantsDonor and Recipient Age
0.25, p<0.0001
(Transplants: January 2009 – June 2016)
• Observation Period 2003 – 2014• Increase in LVAD Implants 3% to 11% • 17 fold Increase in 75 yrs old patients• Overall Increase 5 fold• In Hospital Mortality decreased 61% to 18%• Charlson Comorbidity Index Score >4 33% to 66%• Average Age 77,6 yrs
LVAD use soars in elderly Americans (>75 yrs)published in the The Hospitalist 2017
(A. S. Rali, American Heart Failure Society Meeting )
JACC 57; 25; 2011; 2487
Ann Thorac Surg 2013;96:141-7
Ann Thorac Surg. 2013 Jul; 96(1): 141–147
Conclusions
• Encouraging data• Can be performed safely• Positive impact on patients• Much better than medical therapy• Outcomes inferior to younger patients• careful selection necessary• Risk of RV failure should be low
Frailty
Frailty and Outcomes Following Implantation of Left Ventricular Assist Device as Destination TherapyDunlay SM et al, JHLT2014.33(4):359-365
If I had ONE Wish……??No Anticoagulation
Who are the Payers?Persuading the Payers
Resources for 200 Heart TransplantProcedures
• On Call team 24/7 • Surgeons, anaesthetists, coordinators, ITU, theatres,
tissue typing, NHSBT infrastructure• Expensive and risky air transport for retrieval teams• 15 to 20 people are actively involved for each
procedure• Procedure at night most of the time• Numerous unsuccessful donor runs / transports• Life long centralised follow up • Peer review has been due for long time
Medical Therapy AICD
BV Pacing VAD’s
Advanced Heart Failure
Transplantation
Advantage LVAD‘s• Better early outcomes• Off the shelf• During the daytime, nobody is tired• Controlled, well planned,• LVAD allways works, no „graft failure“• Can be replaced any time• Overall less expensive, low level of infrastructure in
future• Less invasive techniques• Advances in technology • „ just a piece of metal“
Conclusions
• Durable LVAD therapy is as safe as in younger patients groups
• Longer term outcomes are similar• The HRQOL seems to be better • The selection should follow the same guidelines
as in the under 70 yr olds• There is no proof of cost effectiveness in any
patient group• It is not the question of a precious donor Organ• It is “ JUST A PIECE OF METAL”
THANK YOU