LVAD timing: "Doctor, what would you do if it were you?"

Usually, I answer patient queries without much hesitation. It is a rare instance that I must reply: "I would have to think about it a bit more." In the instance of whether or not I'd go for an LVAD to save me from the rigors of congestive heart failure, hands down, if I were experiencing lifestyle limiting shortness of breath, were faced with multiple admissions for heart failure, had huge legs that wept fluid, failed maximum medical therapy with no prospects of titration due to heart-rate/blood-pressure constraints, and were practicing fluid and sodium restriction rigorously to no avail, then I would beg, or better yet, fight for an LVAD.

Many patients fall into the current doughnut hole of VAD implant criteria and drown in a watery grave while we stand on the shore, life preserver in hand, waiting and waiting until their heads no longer bob on the surface. The new implant criteria should acknowledge that it is wholly unfair to ask that the heart be completely incapacitated but pompously insist that renal function be "adequate" in order to proceed with a VAD. This new conclusion can now be drawn, thanks to the body of literature and experience now available with VAD therapy. It would be unfair, however, to proceed without acknowledging that it is also a delicate balance to decide who is too sick for a biventricular pacing device but too well for an LVAD. There will be gray areas, but those questions represent the interface of medicine as both art and science and therefore will require careful consideration from an individualized perspective. 

In prior blogs, I've referred to several patients who have had fantastic success with an LVAD. One of my patients, however, has now passed away. He was the youngest of all the patients and failed two bypass surgeries from diabetes and continued smoking until very late in his disease process. He succumbed to a drive-line infection but lived almost two years with good quality of life provided by God and his device. His youngest children will remember him well. (I confess I have not been able to bring myself to contact his minister, where a posthumous message awaits me.) Another patient, several years out, is still flying high, doesn't want a heart transplant, and hardly has time to keep her appointments because she is too busy. I saw our practice's most recent VAD patient at a play. He had to jump the hurdles of gut bleeding from RV hypertension, angiodysplasia, renal insufficiency, and insulin-requiring diabetes to grab one. In the year following his implant, he drove to my house, stepping out of his truck beaming like he'd just dove "a perfect 10" off a cliff. He's out at the local restaurants. He spent part of the summer on a houseboat. His family had a great Christmas holiday. He's 100 pounds lighter and off insulin. It's nothing short of a miracle and he's having the time of his life because he "has a life." Plugging up at night and unplugging in the morning is a small price to pay from his perspective.

So the optimal approach to the questions regarding timing of LVAD implant is to plow through the morbidity/mortality data for both medical management and device therapy, consider the cost of the implant, the insurance coverage, and then weigh all these things against the cost of repeat hospital admissions for heart failure and pharmaceuticals for our patients and their impact on quality of life. We should then discuss every aspect of both management options with the patient and family, and finally ask ourselves that all-time-favorite-patient-generated question: "Doctor, what would you do if it were you?"

Then, without hesitation and by all means, do it!

See also:

3B or not 3B? Should patients get an LVAD before reaching end-stage HF?

Your comments

	LVAD timing: "Doctor, what would you do if it were you?"
	# 1 of 3	February 2, 2012 10:04 (EST)
	David Kraus	Your comments are well taken! My patients who have received a VAD have done extremely well post-discharge. Getting them through the hospitalization is another thing and can be very tedious and quite difficult as with your last patient described in your text. We are dealing terribly ill population of patients to begin with and presenting them with a therapy that can potentially make them a lot sicker before they begin to get well. I am truly amazed however at the outcomes of these patients once they are "successfully" treated with a VAD whether it is for an acute bailout procedure, bridge to transplant or bridge to decision as some would call it, or destination therapy. It is almost unheard of to have a patient with end-stage HF and renal function that is "normal". The implant criteria must take this into consideration. Those eligible will otherwise become a very small pool of patients with HF as an end stage illness. Hopefully, the new criteria will not only be encompassing of all potential VAD candidates but it will give those of us treating these patients a small light at the end of the tunnel so to speak to make earlier referrals to qualified individuals who are accustomed to treating these patients. Thanks D.Kraus
	# 2 of 3	February 8, 2012 07:49 (EST)
	Pamela Mason	My stepmom had a LVAD implanted in June and it was the best thing ever.  She would have died if it wasn't for this device.  Her cardiologist stated that there was nothing they could do for her and took it upon herself to seek other options.  It is probably a good thing otherwise she would be dead. She has done wonderful with it.  Her only problem with the device is that she is not able to wear a dress and she says she feels like a freak with it.  Well I'd rather feel like a freak and be on earth and not be on earth.  I keep reminding her of that fact.  I am glad this device was available for her.
	# 3 of 3	February 19, 2012 09:51 (EST)
	Melissa	Pamela, I'm so pleased to hear that your step mom is doing well.  Tell her's there is nothing freaky about not wearing a dress, though I'd think someone with alteration capability might help her be able to solve that problem!! Congratulations! David, thanks for your post. I share your concerns and look forward to a future where Vads aren't so difficult to obtain for our patients. Melissa

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