LVAD timing: “Doctor, what would you do if it were you?” blog by Dr. Melissa Walton-Shirley
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!