Aims
During the last decades left ventricular assist devices (LVAD) have assumed a central role in the management of patients with symptomatic end-stage heart failure (HF). The mortality rate and prognosis of these patients is poor, but the substantial progress in LVAD technologies has led to significant improvements in clinical outcomes. The third generation LVADs are small, centrifugal flow pumps, contained within the pericardium and based on full magnetic levitation, which allow to reduce the risks of pump thrombosis. The aim of our study is to evaluate the clinical outcomes and functional capacity of patients with end-stage HF before and after the implantation of a third generation LVAD, the HeartMate 3™.
Methods and results
We evaluated eight patients with end-stage HF, followed to Cardiology Unit of Brotzu Hospital in Cagliari and consecutively implanted with the HeartMate 3™ LVAD in the Cardiac Surgery Unit from 12 May 2017 to 24 October 2019. For each patient we collected socio-demographic and clinical features, as well as laboratory tests, therapy, echocardiographic and haemodynamics parameters and any complication. Most of our patients were male (87.5%), with mean age 65.6 ± 5.7 years and higher prevalence of cardiovascular risk factors, like smoke (87.5%), hypertension (62.5%) and hypercholesterolaemia (62.5%). The etiology of HF was mainly due to idiopatic dilated cardiomyopathy (62.5%) and ischaemic heart disease (25%); the only female patient had a history of iatrogenic dilated cardiomyopathy, post-chemo and radiotherapy. Before the implantation most of our patients experienced severe symptoms, recurrent decompensations resulting in NYHA class IV (50%) and III (37.5%); the 100% was inotrope dependant and needed short-term support devices like IABP (75%) and ECMO (25%); the 62.5% underwent mechanical ventilation. The patients had severe left ventricular (LV) dysfunction, with low LV ejection fraction (18.6 ± 1.8%), cardiac output (3.08 ± 1.2 l/min) and cardiac index (1.81 ± 0.83 l/min/m2) and increasing filling pressure (26.5 ± 9.7 mmHg), central venous pression (12.7 ± 5 mmHg) and pulmonary arteries resistance (3.81 ± 1 μW). We also found important LV structural changes, with a severe dilatation and increased volumes (EDV 140.62 ± 67.1 ml/m2; ESV 113.7 ± 55.3 ml/m2). Mild right ventricle dysfunction was present only in 50% of patients with normal diameters. We observed few complications, mainly driveline infections (42.8%) and only one case of in-hospital mortality due to multiple organ failure. The seven patients presenting at FU shown a significant improvement in everyday symptoms and functional capacity compared to pre-operative features (P = 0.029). We also found a mild improvement of systolic LV function compared to pre-operatory values, with increase of CO (3.58 ± 0.65 l/min vs. 3.08 ± 1.2) and EF (21.2 ± 9.4% vs. 18.71 ± 97) even though not statistically significant.
Conclusions
Our study confirms that patients with end-stage HF are mostly male, older, experience severe symptoms and require frequent hospitalizations. The survival rate reached the 87.5% and remained stable even three years after implantation. On the whole our study showed that LVADs can significally improve clinical outcomes and survival rates, confirming the role as treatment of choice for many patients with end-stage HF who cannot undergo heart transplantation, which still remains the gold standard. The complications related to LVAD were few, thanks to careful patients selection, showing a favourable risk benefit ratio.
