Trends in left ventricular assist device use and outcomes among Medicare beneficiaries, 2004–2011

Objective: To characterise the trends in the left ventricular assist device (LVAD) implantation rates and outcomes between 2004 and 2011 in the Medicare population. Since the approval of the HeartMate II in 2008, the use of LVADs has steadily climbed. Given the increase in LVAD use, issues around discharge disposition, post-implant hospitalisations and costs require further understanding. Methods: We examined LVAD implantation rates and short-term and long-term outcomes among Medicare fee-for-service beneficiaries hospitalised for LVAD implantation. We also conducted analyses among survivors 1-year post-discharge to examine rehospitalisation rates. Lastly, we reported Centers for Medicare & Medicaid Services (CMS) payments for both index hospitalisation and rehospitalisations 1 year post-discharge. Results: A total of 2152 LVAD implantations were performed with numbers increasing from 107 in 2004 to 612 in 2011. The 30-day mortality rate decreased from 52% to 9%, and 1-year mortality rate decreased from 69% to 31%. We observed no change in overall length of stay, but post-procedure length of stay increased. We also found an increase in home discharge dispositions from 26% to 53%. Between 2004 and 2010, the rehospitalisation rate increased and the number of hospital days decreased. The adjusted CMS payment for the index hospitalisation increased from $188 789 to$225 697 over time but decreased for rehospitalisation from $60 647 to$53 630. Conclusions: LVAD implantations increased over time. We found decreasing 30-day and 1-year mortality rates and increasing home discharge disposition. The proportion of patients rehospitalised among 1-year survivors remained high with increasing index hospitalisation cost, but decreasing post-implantation costs over time

Ischemic cardiomyopathy is an independent predictor of mortality in patients presenting for Heart Mate II left ventricular assist device implantation

Objective: No clinical study compares outcomes of left ventricular assist device (LVAD) implantation in patients with end-stage heart failure secondary to ischemic cardiomyopathy (ICM) and non-ICM (NICM). The purpose of this study is to analyze the outcome of LVAD therapy in these 2 cohorts of patients. Materials and Methods: Forty-four patients had HeartMate II LVAD implantation between September 2012 and August 2014. Charts were retrospectively reviewed and data accumulated were statistically analyzed. Results: A total of 23 (52%) patients were presented with ICM. Average age in ICM was 63.7 ± 6.8 years as opposed to 53.9 ± 16.3 in NICM (P = 0.017). About 78% of ICM and 67% of NICM group were male (P = 0.388). 43.5% of ICM had undergone previous cardiac operation versus 9.5% of NICM (P = 0.012). Implant strategy was bridge to transplant in 78% of ICM and 67% of NICM (P = NS) and destination therapy in 22% of ICM and 33% of NICM (P = NS). A thirty-day mortality rate was 17% in the ICM and 0% in the NICM (P = 0.06). One-year mortality was 39% for ICM and 19% for NICM (P = 0.14). On multivariate analysis, ICM emerged as an independent predictor of mortality (odds ratio: 3.19). Variables such as serum creatinine, inotropic or vasopressor requirement, intraaortic balloon pump use, or complex operations involving aortic or tricuspid valves at the time of LVAD placement did not impact mortality. Conclusions: This report, based on a nonmatched cohort of 44 patients, demonstrates that in an era of selective criteria for LVAD implantation, ICM emerges as an independent predictor of mortality. These patients tend to be older and are more likely to be undergoing reoperative sternotomy. These results should form the basis for a larger scale investigation of LVAD implantation in ICM patients

Comparative survival and cost-effectiveness of advanced therapies for end-stage heart failure.

BackgroundTreatment options for end-stage heart failure include inotrope-dependent medical therapy, orthotopic heart transplantation (OHT), left ventricular assist device (LVAD) as destination therapy or bridge to transplant.Methods and resultsWe developed a state-transition model to simulate 4 treatment options and associated morbidity and mortality. Transition probabilities, costs, and utilities were estimated from published sources. Calculated outcomes included survival, quality-adjusted life-years, and incremental cost-effectiveness. Sensitivity analyses were performed on model parameters to test robustness. Average life expectancy for OHT-eligible patients is estimated at 1.1 years, with 39% surviving to 1 year. OHT with a median wait time of 5.6 months is estimated to increase life expectancy to 8.5 years, and costs <$100,000/quality-adjusted life-year gained, relative to inotrope-dependent medical therapy. Bridge to transplant-LVAD followed by OHT further is estimated to increase life expectancy to 12.3 years, for$226,000/quality-adjusted life-year gained versus OHT. Among OHT-ineligible patients, mean life expectancy with inotrope-dependent medical therapy is estimated at 9.4 months, with 26% surviving to 1 year. Patients who instead received destination therapy-LVAD are estimated to live 4.4 years on average from extrapolation of recent constant hazard rates beyond the first year. This strategy costs $202,000/quality-adjusted life-year gained, relative to inotrope-dependent medical therapy. Patient's age, time on wait list, and costs associated with care influence outcomes.ConclusionsUnder most scenarios, OHT prolongs life and is cost effective in eligible patients. Bridge to transplant-LVAD is estimated to offer >3.8 additional life-years for patients waiting ≥6 months, but does not meet conventional cost-effectiveness thresholds. Destination therapy-LVAD significantly improves life expectancy in OHT-ineligible patients. However, further reductions in adverse events or improved quality of life are needed for destination therapy-LVAD to be cost effective