Too Well for an LVAD?

There is a lack of data regarding the outcomes of patients who were subjectively assessed to have advanced heart failure (AdvHF) and therefore offered evaluation for left ventricular assist devices (LVADs) only to be determined to be "too well". We retrospectively reviewed all referrals to our Advanced Heart Failure outpatient clinic for LVAD evaluation from 1/1/13 to 12/31/17. Those individuals who were above the age of 18, subjectively determined to have a syndrome of AdvHF as assessed by a HF Faculty, but deemed "too well" for implantation after formal VAD evaluation and multidisciplinary Medical Review Board (MRB) discussion were included for analysis. 62 patients met inclusion criteria. 75% were male, median age at time of presentation to MRB was 57.5 years. Median time to MRB presentation from initial out-patient consultation was 33.5 days. Medication titration was recommended to nearly all (98%), while concomitant evaluation for stem cell therapy and inotropic support was recommended in 17% and 15% respectively. Median time to initial follow-up after MRB presentation was 29.5 days. Beyond initial follow-up 26% were lost to follow-up. Men were 31% more likely than women to be lost to follow up (p = 0.019). Of those who continued to follow in our system, survival 1 year after MRB presentation was 94%, during which time 28% required at least one unscheduled clinic visit, 25% required ED treatment and 27% required at least one hospitalization. 10 patients ultimately were represented to the MRB at a median time of 391 days after initial presentation. Of these, 3 patients were ultimately implanted with an LVAD. 26% of patients given the label of "too well" were noted to have relative contraindications precluding them from consideration. Patients determined to be "too well" for LVAD despite a subjective assessment suggestive of a syndrome of AdvHF have good 1 year survival. However, the rates of follow-up and MRB re-discussion, as well as rates of implantation at later dates for "too well" patients is relatively low, despite the known progressive nature of HF. The "too well" label may diminish the perceived need for these patients to have close follow-up with an advanced heart failure team. Additionally, its use may be inaccurate and therefore should be avoided. [ABSTRACT FROM AUTHOR]