• http://www.theprisma.co.uk/wp-content/uploads/2013/01/Voz-contra-01.jpg

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