Background A left ventricular assist device (LVAD) improves survival and quality of life for many, but not all, patients with end-stage heart failure who are ineligible for transplantation. We sought to evaluate the frequency of poor outcomes using a novel composite measure that integrates quality of life with mortality. Methods and Results Within the INTERMACS national registry, poor outcome was defined as death or an average Kansas City Cardiomyopathy Questionnaire<45 over the year following LVAD (persistently limiting heart failure symptoms and poor quality of life). Among 1638 LVAD patients, 29.7% had a poor outcome, with death in 22.4% and persistently poor quality of life in 7.3%. Patients who had a poor outcome were more likely to have higher body mass indices (29.3 vs. 28.2 kg/m2, p=0.007), lower hemoglobin levels (11.1 vs. 11.4 g/dL, p=0.005), prior cardiac surgery (47.8% vs. 39.8%, p=0.004), history of cancer (13.8% vs. 9.7%, p=0.025), severe diabetes (15.6% vs. 11.5%, p=0.038), and poorer quality of life pre-implant (KCCQ scores: 29.8 vs. 35.3, p<0.001). Conclusions Nearly one-third of patients die or have a persistently poor quality of life over the year after LVAD. We identified a number of factors associated with a poor outcome, which may inform discussions prior to LVAD implantation to enable more realistic expectations of recovery.

SYNOPSIS Clinical practice guidelines endorse the use of palliative care in patients with symptomatic heart failure. Palliative care is no longer seen as “giving up” or “accepting death,” but is now conceptualized as “supportive care” afforded to most patients with chronic, life-limiting illness. However, the optimal content and delivery of palliative care interventions remains unknown and its integration into existing heart failure disease management continues to be a challenge. Therefore, we will comment on the current state of multidisciplinary care for such patients, explore evidence supporting a team-based approach to palliative and end-of-life care for patients with heart failure, and identify high-priority areas for research. Ultimately, patients require a “heart failure medical home”, where various specialties may take a more central role in coordination of patient care at different times in the disease span, sometimes transitioning leadership from primary care to cardiology to palliative care.