Reversibility of Frailty After Bridge-to-Transplant Ventricular Assist Device Implantation or Heart Transplantation

Abstract

BackgroundWe recently reported that frailty is independently predictive of increased mortality in patients with advanced heart failure referred for heart transplantation (HTx). The aim of this study was to assess the impact of frailty on short-term outcomes after bridge-to-transplant ventricular assist device (BTT-VAD) implantation and/or HTx and to determine if frailty is reversible after these procedures.MethodsBetween August 2013 and August 2016, 100 of 126 consecutive patients underwent frailty assessment using Fried’s Frailty Phenotype before surgical intervention: 40 (21 nonfrail, 19 frail) BTT-VAD and 77 (60 nonfrail, 17 frail) HTx—including 17 of the 40 BTT-VAD supported patients. Postprocedural survival, intubation time, intensive care unit, and hospital length of stay were compared between frail and nonfrail groups. Twenty-six frail patients were reassessed at 2 months or longer postintervention.ResultsFrail patients had lower survival (63 ± 10% vs 94 ± 3% at 1 year, P = 0.012) and experienced significantly longer intensive care unit (11 vs 5 days, P = 0.002) and hospital (49 vs 25 days, P = 0.003) length of stay after surgical intervention compared with nonfrail patients. Twelve of 13 frail patients improved their frailty score after VAD (4.0 ± 0.8 to 1.4 ± 1.1, P < 0.001) and 12 of 13 frail patients improved their frailty score after HTx (3.2 ± 0.4 to 0.9 ± 0.9, P < 0.001). Handgrip strength and depression improved postintervention. Only a slight improvement in cognitive function was seen postintervention.ConclusionsFrail patients with advanced heart failure experience increased mortality and morbidity after surgical intervention with BTT-VAD or HTx. Among those who survive frailty is partly or completely reversible underscoring the importance of considering this factor as a dynamic not fixed entity.

The Continuum of Aging and Age-Related Diseases: Common Mechanisms but Different Rates

“…An impressive amount of literature has been published suggesting that a complex network of clinical signs produce a large spectrum of frailty conditions and phenotypes ( 47 ) with different risk index of mortality after 3–5 years of follow-up. Surprisingly, the condition of frailty may be reverted and subjects can return to a non-frail condition, for example, when specific pathologies are cured, or personalized interventions in terms of physical exercise, with or without nutrition supplementation, are applied ( 48 , 49 ).…”

Physical frailty after liver transplantation

“…by 3 months after transplant surgery (as compared to their frailty score at the time of kidney transplantation) 17. Among 13 frail (again, by the Fried Frailty Index 11 ) patients with heart failure, nearly all (n = 12) experienced reversal of their frailty after heart transplantation at a median of 6 months after surgery, although data regarding the extent of their improvement (ie, whether they became robust) are lacking 18. While kidney and heart transplant surgery may be associated with less morbidity than liver transplant surgery, our data in liver transplant recipients stand in stark contrast to these other solid organ transplant recipients, highlighting the need for organ-specific efforts to improve frailty both pre-and posttransplantation.…”

“…Hypertension and diabetes were prevalent in 43% and 25%, respectively. Median (interquartile range [IQR]) laboratory MELD scores at frailty assessment and at transplant for the entire cohort were 15(11)(12)(13)(14)(15)(16)(17)(18) and 20(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27). Seven…”

Heart Failure and Frailty in the Community-Living Elderly Population: What the UFO Study Will Tell Us

“…Importantly, frailty has a considerable negative impact on patients with HF, as the presence of frailty increases the risk for both hospitalization and death by at least 1.5-fold (Lupón et al, 2008 ; Afilalo et al, 2009 ). In advanced HF patients undergoing LVAD implantation or heart transplantation, preoperative frailty assessment can indicate those with increased postoperative risks of death, prolonged utilization of intensive care unit and length of hospital stay (Jha et al, 2016 , 2017 ). Importantly, frailty can reverse or be improved in some patients with HF (Lee et al, 2014 ; Jha et al, 2016 ; Maurer et al, 2017 ), refuting the notion that frailty is permanent, inevitably irreversible and age-dependent.…”

“…In patients with chronic HF, multidisciplinary interventions including strength and muscle training, physical rehabilitation, and nutritional supplementation may improve functional impairment and deficits (Piepoli et al, 2004 ; O'Connor et al, 2009 ; Davies et al, 2010 ; Rozentryt et al, 2010 ; Avni et al, 2012 ; Gotsman et al, 2012 ; Taylor et al, 2014 ). Furthermore, in eligible candidates frailty may be reversible with left ventricular assist device (LVAD) therapy or heart transplant (Jha et al, 2016 , 2017 ; Maurer et al, 2017 ). However, these advanced therapies are costly and may not be available or suitable for many patients with HF.…”