Functional Status in Left Ventricular Assist Device–Supported Patients: A Literature Review

doi:10.1016/j.cardfail.2014.08.011

Journal of Cardiac Failure

Volume 20, Issue 12, December 2014, Pages 973-983

https://doi.org/10.1016/j.cardfail.2014.08.011 Get rights and content

Highlights

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LVAD patients demonstrate improvement to NYHA functional class I-II throughout first year of therapy, with largest functional gains made during the first 6 months of therapy.
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Physical training intervention studies have demonstrated prevention of weight gain, increased 6-minute walk test distances, and improved pulmonary function, but further intervention studies are needed.
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Pump speed alterations have produced varied results, but further studies should consider the value of submaximal exercise testing which may more clearly reflect the functional gains that patients experience.

Abstract

The prevalence of advanced heart failure (HF) is increasing because of the aging population and improvements in HF management strategies. Left ventricular assist device (LVAD) technology and management continue to advance rapidly, and it is anticipated that the number of LVAD implants will increase. LVADs have been demonstrated to extend life and improve outcomes in patients with advanced HF. The purpose of this article is to review and synthesize the evidence on impact of LVAD therapy on functional status. Significant functional gains were demonstrated in patients supported by LVAD throughout the 1st year, with most improvement in distance walked and peak oxygen consumption demonstrated in the 1st 6 months. Interventions to enhance exercise performance have had inconsistent effects on functional status. Poor exercise performance was associated with increased risk of adverse events. Functional status improved with LVAD therapy, although performance remained substantially reduced compared with age-adjusted norms. There is tremendous need to enhance our understanding of factors influencing functional outcomes in this high-risk population.

Section snippets

Left Ventricular Assist Devices Improve Functional Status

According to the American Heart Association, in 2014 there were 5.1 million American adults diagnosed with heart failure (HF).¹ This growing number is attributable to the aging of the population as well as overall improvements in HF management. Of patients with advanced HF, <4,000 are on the waiting list for heart transplants.2, 3 Although 2,506 left ventricular assist devices (LVADs) were implanted in 2013 in the USA, it is estimated that 40,000–200,000 HF patients may benefit from the support

Search Methods

A systematic literature search of the Pubmed and Cinahl databases was conducted. Search terms included the MESH term “heart-assist device” as well as “left ventricular.” For functional status, the terms “functional capacity,” “functional status,” “exercise capacity,” “exercise tolerance,” and “exercise performance” were used. “Quality of life” was added to the search list because in HF, QOL is often measured with a parallel functional measurement. In addition, the references of the articles

Functional Gains Measured by a 6-Minute Walk Test

Before LVAD insertion, most HF patients were classified with New York Heart Association (NYHA) functional class IV, with many dependent on inotrope therapy, therefore unable to perform exercise testing.¹⁴ Studies mapping the recovery and functional gains of LVAD recipients found an increase of cardiac output within 2 days of insertion.¹⁷ Functional gains were demonstrated as early as 1 month.14, 18, 19, 20 NYHA functional class improved to I–II in nearly one-half of the sample at 1 month after

Physical Training Shows Modest Benefit in Small Studies

Interventional studies were conducted in various countries to examine the effect of physical training and other lifestyle-related interventions on functional status. Intervention studies are summarized in Table 3. Physical training studies used multifaceted intervention strategies to enhance functional status, although no 2 studies used the same combination of strategies.18, 21, 28 Intervention strategies included dietary coaching, psychosocial counseling, aerobic training, strength training,

Disclosures

Dr Russell is a consultant for and has received research support from Thoratec.

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Cited by (40)

Blood type O heart transplant candidates have longer waitlist time and higher delisting under the new allocation system
2024, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
This trend mirrors the likelihood of survival to HTx in prior analyses, thus indicating that decreased survival to HTx among blood type O candidates due to increased durable LVAD dependence may be a just reflection of natural disease progression. This perspective is purely utilitarian; however, and relies on the assumption that receiving a HTx and surviving with a durable LVAD on the waitlist permit similar quality of life.15,16 It remains unknown whether or not current generation durable LVADs permit comparable quality of life to HTx.
Prior studies have examined the effect of blood type on heart transplantation (HTx) waitlist outcomes in cohorts through 2015. We aim to analyze the effect of blood type on contemporary waitlist outcomes with a new allocation system focus.
Adults listed for HTx between April 2015 and December 2020 were included. Survival to HTx and waitlist death/deterioration was compared between type O and non-type O candidates using competing risks regression. Donor/recipient ABO compatibility trends were further investigated.
Candidates with blood type O (n = 7509) underwent HTx less frequently than candidates with blood type other than type O (n = 9699) (subhazard ratio [sHR], 0.56; 95% CI, 0.53-0.58) with higher rates of waitlist death/deterioration (sHR, 1.18; 95% CI, 1.04-1.34). Subgroup analyses demonstrated persistence of this trend under the new donor heart allocation system (HTx: sHR, 0.58; 95% CI, 0.54-0.62; death/clinical deterioration: sHR, 1.27; 95% CI, 1.02-1.60), especially among those listed at high status (1, 2, or 3) (HTx: sHR, 0.69; 95% CI, 0.63-0.75; death/deterioration: sHR, 1.61; 95% CI, 1.16-2.22). Among those listed at status 3, waitlist death/deterioration was modified by presence of a durable left ventricular assist device (left ventricular assist device: sHR, 1.57; 95% CI, 0.58-4.29; no left ventricular assist device: sHR, 3.79; 95% CI, 1.28-11.2). Type O donor heart allocation to secondary ABO candidates increased in the new system (14.5% vs 12.0%; P < .01); post-HTx survival remained comparable between recipients with blood type O and non-type O (log-rank P = .07).
Further logistical considerations are warranted to minimize allocation inequity regarding blood type under the new allocation system.
Patient-Reported Outcomes Measurement Information System (PROMIS) in Left Ventricular Assist Devices
2022, Annals of Thoracic Surgery
Citation Excerpt :
All PROMIS instruments are designed to have a mean score of 50 with SD of 10 in the general population. The mean physical function for LVAD patients in the present study was less than that of the general population, supporting previous work that showed LVAD patients typically have lower physical function than age-adjusted norms using other PRO instruments.23 In terms of pain and depression, LVAD patients had comparable levels of both pain interreference and depression as the general population on average.
Appropriate collection of quality of life measurements for left ventricular assist device (LVAD) patients is challenging. Patient-Reported Outcomes Measurement Information System (PROMIS) is a popular tool that has been validated across multiple disciplines, but its applicability to the LVAD population remains unknown.
This single-center, retrospective review included LVAD patients who completed a PROMIS assessment and Kansas City Cardiomyopathy Questionnaire (KCCQ-12) survey at clinical encounters postoperatively. Patients completed computer adaptive PROMIS assessments for physical function, pain interference, and depression. All PROMIS domains are designed to follow a normal distribution (mean T-score 50, SD 10) in the general population. Assessments were aggregated over time and correlation between the KCCQ-12 summary score and each PROMIS domain was assessed individually.
A total of 178 LVAD patients were included in the study. The median time between LVAD implantation and PRO collection was 16.5 [interquartile range, 7.9-37.8] months. Patients typically had worse physical function (T-score 38.8 [33.6-44.2]) but comparable pain (51.1 [38.7-59.2]) and depression (49.9 [41.7-57.5]) as the general population. The KCCQ-12 was more strongly correlated to PROMIS physical function (Spearman’s ρ = 0.746) than pain (ρ = –0.539) or depression (ρ = –0.591).
PROMIS provides a robust quality of life data collection system that can be implemented in a clinical setting without imposing a significant burden. Using this more holistic system may allow for better patient-centered care in order to address quality of life limitations imposed by LVAD support that are not directly related to heart failure symptoms.
Role of Cardiac Rehabilitation After Ventricular Assist Device Implantation
2021, Heart Failure Clinics
Citation Excerpt :
It has been reported that when the hemodynamics of a patient are stable after LVAD implantation, some physical rehabilitation may begin with the aim of restoring a minimum of mobility independence.33,34 Some studies have also reported that after rehabilitation LVAD patients improved in anxiety, depression, and QoL, and caregivers reduced their strain.35 The ability of LVAD patients to achieve a minimum level of physical fitness after CR seems to be associated with improved long-term survival, as reported in a study in which patients who walked more than 300 m on a 6-minute walk test conducted for more than 2 months after device implantation presented a significantly lower risk for future all-cause mortality.36
Hemodynamic Response to Exercise in Patients Supported by Continuous Flow Left Ventricular Assist Devices
2020, JACC: Heart Failure
This study sought to characterize the hemodynamic response to exercise in LVAD-supported patients and identify parameters most strongly associated with peak oxygen consumption (VO₂).
Despite improved survival for heart failure patients afforded by continuous flow left ventricular assist devices (LVADs), peak exercise capacity remains impaired. Mechanisms underlying this reduced functional capacity remain poorly understood.
Patients referred for post-VAD hemodynamic optimization from December 2017 through June 2019 were enrolled. Swan Ganz catheters were inserted and upright incremental bicycle ergometry with respiratory gas analysis was performed. Hemodynamic measurements, mixed venous saturation, and arterial blood pressure were recorded every 3 min during exercise. Linear correlations were performed between peak VO₂ (ml/min) and peak Fick cardiac output (CO), peak device flow, the assumed intrinsic CO derived as Fick CO-device flow, peak pressure differential across the LVAD (mean arterial pressure−pulmonary capillary wedge pressure), peak pressure differential across right ventricle (mean pulmonary artery pressure − right atrial pressure) and systemic vascular resistance.
Forty-five patients supported by axial flow pumps (n = 12) and centrifugal flow pumps (n = 33) were studied. There were 34 men and 11 women. Age averaged 60 ± 10 years. Peak VO₂ averaged 10.6 ± 3.1 ml/kg/min. Fick CO had the greatest correlation with peak VO₂ with r = 0.73 (p < 0.0001) followed by intrinsic CO (r = 0.67; p < 0.0001). Multivariate model that best predicted peak VO₂ included Fick CO and peak arterial venous oxygen (AVO₂) difference.
LVAD supported patients have severely impaired peak exercise capacity. The peak Fick cardiac output was the best correlate of peak exercise performance.
Impact of LVAD speed change on physiologic functions
2019, Journal of Heart and Lung Transplantation
Psychosocial and quality of life issues in mechanical circulatory support
2019, Mechanical Circulatory Support: A Companion to Braunwald’s Heart Disease
The use of mechanical circulatory support (MCS) as a long-term therapy for end-stage heart failure is associated with many psychosocial considerations for both patients and their families. These considerations span the process of care: they encompass factors including evaluation, informed consent, and decision-making before implantation; health-related quality of life and behavioral outcomes during and after MCS implantation; impact of psychosocial factors on clinical outcomes after MCS implantation; and end-of-life concerns. Like many other medical interventions, the success of MCS is ultimately judged by its ability not only to prolong life but also to maximize psychosocial and physical well-being. Hence, it is critical for health care providers and researchers alike to understand the key psychosocial issues that emerge at each step in the process of MCS intervention, as well as the empirical evidence available regarding them. Better understanding of the issues and related evidence is important for improved education of patients and their families, especially since long-term MCS is a viable treatment option. It is also important for the development and evaluation of new strategies to maximize psychosocial outcomes in patients receiving MCS.

View all citing articles on Scopus

: Funding: National Institute of Nursing Research (National Institutes of Health T32 NR 012704), Heart Failure Society of America Nurse Research Grant (2014–2016), and Predoctoral Training in Research Program (National Institutes of Health 5TL1TR001078–02 (2014–2015).

: See page 982 for disclosure information.

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Review ArticleFunctional Status in Left Ventricular Assist Device–Supported Patients: A Literature Review

Highlights

Abstract

Section snippets

Left Ventricular Assist Devices Improve Functional Status

Search Methods

Functional Gains Measured by a 6-Minute Walk Test

Physical Training Shows Modest Benefit in Small Studies

Disclosures

Am J Transpl

J Heart Lung Transpl

J Heart Lung Transpl

J Heart Lung Transpl

Ann Thorac Surg

J Heart Lung Transpl

J Am Coll Cardiol

J Heart Lung Transpl

J Heart Lung Transpl

J Am Coll Cardiol

J Heart Lung Transpl

J Heart Lung Transpl

Am J Cardiol

J Heart Lung Transpl

J Heart Lung Transpl

J Heart Lung Transpl

PM R

Arch Phys Med Rehabil

Heart Lung

J Heart Lung Transpl

Heart disease and stroke statistics—2014 update: a report from the American Heart Association

Circulation

Introduction

Am J Transpl

Quarterly statistical report 2013 4th quarter

Left ventricular assist devices are underutilized

Circulation

Outcomes of left ventricular assist device implantation as destination therapy in the post-REMATCH era: implications for patient selection

Circulation

Review Article
Functional Status in Left Ventricular Assist Device–Supported Patients: A Literature Review