Is a left ventricular assist device (LVAD) a good treatment option?

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute. These podcasts will help you learn more about your heart, thoracic and vascular systems, ways to stay healthy, and information about diseases and treatment options. Enjoy!

Michael Tong, MD:

Good morning.

Anthony Zaki, MD:

Good morning.

Michael Tong, MD:

My name is Dr. Michael Tong and I'm here with Dr. Anthony Zaki. We're both cardiovascular surgeons here at Cleveland Clinic, and we both specialize in heart failure. I'm the director of heart transplantation and mechanical circulatory support. So today, we are going to be talking about LVADs or left ventricular assist devices. What are these devices? How might they help you? What are the outcomes, and what we do here at Cleveland Clinic with LVADs and how that fits into the armamentarium of treatment options for our patients. So Dr. Zaki, let's first give our audience and our patients an idea. How does the heart function just on broad strokes?

Anthony Zaki, MD:

Sure. Our heart is a very elegant organ. Blood comes in through the body, enters into the right side [of the heart]. It's then pumped into the lungs where it receives oxygen and other nutrients, and then is returned to the left side of the heart where it's pumped to the rest of your body. There's a lot of components. There's an electrical system, there are valves, but that's the main overview.

Michael Tong, MD:

Okay, great. And the heart is really, truly a miraculous organ. We have really the benefit of having a whole team here, and we're able to take patients of all spectrums of heart disease. Now, the specific patients that we're talking about today are patients who have heart failure. Can you explain a little bit to the audience what heart failure is and how common that disease process can be?

Anthony Zaki, MD:

Sure. Heart failure is a common pathway that people with any heart disease may progress to where the heart, for whatever reason, is failing to meet the demands of the body. Whether it's a pumping failure, an electrical failure, where that process that we described of the blood moving through the heart is impeded or slowed for whatever reason and unable to meet the demands of the body. It's a very common problem.

Michael Tong, MD:

Yeah, indeed. And when we think about heart failure, it's really truly a spectrum of disease. You have some patients that have very mild heart failure. They may just be a little fluid overloaded and we can help them with some medications. And for a majority of patients with heart failure, our team of clinicians or cardiologists here are able to keep them going for many, many years. And however, there are some patients where, because of a previous heart attack or for other reasons, get to the very end stage where the medications are no longer effective. Now we have to admit them to hospital and keep them on intravenous medications. So let's talk about that group of patients. When that happens, when patients get to the point where the medications have all been exhausted, their traditional cardiac surgery options are no longer an option for them or they've already been done, what are the typical treatments that we have left when patients truly are at the end stage heart failure?

Anthony Zaki, MD:

Yeah, great question. The people that progress to this stage, what we call advanced heart failure, we have a specialized team here that takes care of these patients especially, and there are therapies that we can offer that are very effective. Classically, the most common and the most effective treatment was heart transplantation. And we're still doing that very commonly for the patients that are appropriately selected. In the country total, there's almost close to 4,000 transplants being done every year. But that is not sufficient to meet the needs of all these patients with advanced heart failure or end stage heart failure. And this is where LVADs or left ventricular assist devices come into play to help fill that gap of all the patients that meet that category of advanced heart failure, but for whatever reason are not candidates for heart transplantation, or due to the scarcity of organ donors, or long waiting times are just unable to get a heart transplant. And so an LVAD for the appropriately-selected patient and then the right team is a great therapy.

Michael Tong, MD:

Yeah, great. Yeah, I totally agree. For the number of patients around the country and around the world even who need advanced treatments, the supply of organs unfortunately just really isn't sufficient to meet their demand. And this is really the beauty of the LVAD, isn't it? We can do this operation at any time. We have these devices that are available to us that we can do it at any time. So when we look at, across the country, why isn't that every patient is a candidate for heart transplant?

Anthony Zaki, MD:

Well heart transplantation, because of its scarce organ [availability] and because of the degree of immune suppression that's required, there are a group of patients that just will not benefit from the procedure or are just not candidates for the procedure. That might be a recent cancer or someone who's out of the age range or, for whatever reason, they're too sick to undergo a heart transplantation. There's a whole host of reasons.

Michael Tong, MD:

And can you give the audience a bit of an idea of what the typical wait time is for a transplant?

Anthony Zaki, MD:

Well, we prioritize our patients on the waiting list based on the urgency. They're given a classification, and we prioritize our patients that are the sickest. So they have the shortest waiting times. And those are most often our patients that are in the hospital and are too sick to either leave the intensive care unit or even leave the hospital at all. And those are the patients that have the shortest waiting times, but even for them, they can sometimes wait days to weeks. For the vast majority of our patients who have heart failure, who are managed on medications at home, but are still classified as advanced and are needing a heart transplant, those wait times can be months to even years. And so those patients have longer waiting times, and sometimes waiting for a heart transplant is not a great option or we need something else to get them there.

Michael Tong, MD:

And we do see this all the time, patients are waiting, we're waiting for a heart for them, and unfortunately they just run out of time. We try to keep them going for as long as possible, but it gets to the point where their other organs are starting to fail. We see their livers starting to fail. We see their kidneys starting to fail. Their quality of life is greatly diminished. They sometimes get to the point where they feel like life is passing them by and they're just in a holding pattern, and they never know if they're going to see the next holidays. They don't know if they're going to make it to the next year or see their grandkids grow up. And I think really for that group of patients, even though they may be transplant candidates, I think this is where left ventricular assist device can really be a key benefit for them. And that's a large group of our patients that we do end up doing a left ventricular assist device. Now, after a patient receives a ventricular assist device, are they no longer considered transplant candidate? Or how would you classify them and how will we continue to care for them lifelong?

Anthony Zaki, MD:

Yeah, not at all. If you receive a left ventricular assist device, or an LVAD, you can still become a candidate for heart transplantation. So classically, when we put these left ventricular assist devices - at the time that we surgically implant the device, they're classified as either a bridge to transplantation or what we call a destination therapy. Now, the first category, bridge to transplantation, means that you are a candidate for heart transplant, but for the reasons that we discussed earlier (a long waiting time or maybe you're getting sicker and just can't wait the expected time that you will probably wait), a left ventricular assist device can be placed to buy time or to help bridge the time needed until heart transplantation. Now, the second category is called a destination therapy. And all that means is that at the time that the LVAD is put in, you are not a candidate for heart transplantation. Now, that doesn't mean that down the road you can't become a candidate for your heart transplantation, but that means that at the time the device is put in, the goal is for it to stay in long-term.

Michael Tong, MD:

Yeah. And nowadays, we really think about LVADs as short-term or long-term. So the whole designation of bridge to transplant or destination, we don't really think about that anymore. Now, we just think about for patient at this moment, what is the best treatment for you. And you're absolutely right, we always try to get patients to whatever treatment that they may need to live as long of fulfilling the life as you can. And this is truly where the magic of a place like Cleveland Clinic where we have that ability to longitudinally follow patients. And when I meet with patients and I often tell them, "We're partners now. We're going to try to keep you going for the next 10, 20 years if not longer." And that can include a whole slew of various devices and treatments and options. So let's take a step back a little bit and talk about what is an LVAD. When you think about a mechanical pump inside your heart, this sounds like something out of science fiction. So for the audience who are maybe hearing about LVADs for the first time, why don't we break it down? What is an LVAD? What are the components and how does it work?

Anthony Zaki, MD:

Sure. An LVAD, a left ventricular assist device, is a mechanical pump that is surgically implanted. It sits at the bottom of the heart and it helps support the heart. Classically, it supports the left side of the heart. So as we said earlier, the left side of the heart is the pumping chamber that takes blood from the lungs and pushes it into the rest of your body. That heavily oxygenated and nutrient rich blood is pushed out to the body on the left side, ejected out. And so the left ventricular assist device sits at the bottom of the left heart, and it's a mechanical pump that will eject blood using a motor out into the rest of your body. And it works in conjunction with your normal heart. It in no way replaces your heart, but works together with your heart. And these patients with heart failure, they need that extra support.

Now the different components, there's the pump and that is surgically implanted and that is completely inside of the chest. That part is not visible. The drive line is the power cord. It contains all the electrical components. And that exits the body through a small incision on the abdomen, either on the left side or on the right side, well below the rib cage. And that drive line connects to the controller where we can look at the different parameters of the pump, the different things that we follow, like speed and flow and power. And then the last component is the battery, which provides the power for the whole system.

Michael Tong, MD:

Terrific. And when patients come and see us, we will show them what the device looks like. Before they even get the surgery, we often will do training with them to show them exactly how these devices work, how the connections are made, how the batteries are done, not just with the patient, but also with their caretakers and their families. And I think one of the most unique things that we do here is before any patient receives an LVAD, we want them to meet with another patient who has an LVAD so they can have a better idea firsthand what living life with an LVAD is and how they're able to take care of it.

And I think a lot of times what I have noticed is that patients come in with a lot of preconceived notions. And then once they see a patient who has an LVAD and see that they are playing golf, they're playing tennis, they're really living life to the fullest and how much of a difference the LVAD has made for their quality of life, often that is the driver for them to finally realize, yes, this is the right treatment for me. Because most patients that come in and we're talking to them about advanced heart care treatments and LVADs, it is something that's completely daunting. Another thing I wanted to ask you, maybe you can shed some light, is when patients have heart failure, is it usually the left heart that fails or the right heart, or is it both? And when we talk about LVADs, we're only treating the left heart. Can you help the audience maybe understand a little bit the difference between the left and the right heart failure?

Anthony Zaki, MD:

Sure, that's a great question. The LVAD or the left ventricular assist device is primarily for the left side. So it only supports half of the heart. Now, when you support the left side, there is some benefit for the other side. It does provide overall benefit, but for some patients who have primarily a right-sided heart failure, an LVAD surgery may not be the best option for you. And then those are the patients like we were discussing earlier, who may benefit from heart transplant and don't qualify for LVAD surgery. So patients that have primarily left heart failure, which is traditionally the most common type of heart failure, what they can experience is shortness of breath or there's backflow into the lungs which can then transmit to the right side. So often those patients with left ventricular failure can progress to failure on both sides, but it was primarily from a left-sided problem.

Now there is a smaller subset of patients that have primarily right-sided heart failure, and that causes backflow to the rest of the body so they can get lower extremity swelling, they can get this sense of abdominal fullness and issues with the liver congestion and blood flow through the liver. So this is why we look at each one of our advanced heart failure patients very closely and see what therapy is the best for you in your particular pathology or your particular condition, and whether LVAD transplant or neither or some combination is the best option for you.

Michael Tong, MD:

Yeah, I think one of the things that's truly been fascinating as we learn more and more about patient's heart failure over the last decade is just how resilient the right heart is. And we think of the heart as an organ that has two separate circulations going to the lungs and to the body, but really it all works in a series. So you have the right heart that pumps into the lungs. That then goes into the left heart. Then the left heart pumps into the rest of the body. And when you have any part during that whole cascade that's dysfunctional or not working properly, the whole system will back up. So when you have patients that have left ventricular failure, that will then lead to lung problems as you have alluded to, and then that will cause right heart failure.

And I think what we've noticed, and I hope you can elaborate on this, is that most of the patients that come in with, quote/unquote, both left and right heart failure, it's really just left heart failure in disguise. And if we can support the left side, the right side is completely able to keep up and strong enough. I think that also comes to one of the benefits of not waiting too long. As we see patients who have been waiting for a heart transplant or who's been followed by their cardiologists, as they start getting sicker and sicker, eventually the right heart is going to fail as well. And we don't have good treatment options for right heart failure, but I think if we can treat the left heart failure early enough with LVADs, the right heart is able to keep up. Wouldn't you agree?

Anthony Zaki, MD:

Yeah, that's exactly right. And one of the benefits of coming here and coming to Cleveland Clinic is we look at all of these components and where at that pathway is the problem and what therapies can help you. And like Dr. Tong mentioned, we can refer for LVAD or for transplant evaluation early enough before their problem has progressed to right-sided heart failure or even downstream to a kidney problem or a liver problem.

Michael Tong, MD:

So let's talk a little bit about what outcomes patients can expect. An LVAD surgery just seems like such a complex operation, and we do this on a routine basis. So we typically do about 70 to 100 LVADs a year. As of last week, we're the number one implanter of LVAD in the country. And let's talk about some of the outcomes that we can achieve for patients. When patients come in for surgery, what is their likelihood of returning home with a successful operation and what kind of expectations they can have going forward?

Anthony Zaki, MD:

Sure, sure. Like Dr. Tong mentioned, the LVADs are becoming more and more common. We do about 3,000 LVADs in the United States every year. And like Dr. Tong mentioned, we are one of the primary implanters of LVADs in the country. And so we're doing a large majority for a single center of those. Now, for a single patient, what you might expect is we've looked at our own outcomes, and more than 95% of patients after their surgery will be discharged home. That's what you can expect for the vast majority of our patients, which is wonderful. Within one year of your operation, one year of the LVAD being placed, and if you compare that to outcomes in the past of these patients with advanced heart failure, this is just a remarkable difference, that more are still living and are still well compared to what they were before this technology existed.

This is just such powerful technology and therapy that we can offer people. And we have several patients in our program and across the country that are living more than 10 years with their LVAD, and that's amazing to see. And these patients in the past would've waited for a heart transplant, and if they didn't qualify or continued to wait, they would not have been able to expect these types of outcomes. So it's very powerful and we're very proud of those outcomes. And it takes really our whole team to make this happen. But we have a great team here and it's been a wonderful thing to work with.

Michael Tong, MD:

Yeah. And I think it's really important for the audience just to remember or to realize how far this technology has come. I remember as a medical student, I read this paper, this was in the early 2000s, where they looked at patients who were receiving the best medicine at the time versus the first generation LVADs with these massive clunky pumps. And I remember seeing just how sick these patients are. And one of the most striking things I remember is that the two-year survival... So if you had advanced heart failure, the chances of you still being alive in two years was only 8%, 8%. So when you have advanced heart failure, this is a disease that is as bad if not worse than almost any other diseases you can think of. Cancers, we're talking, this is much worse. Your survival is much worse than lung cancer, much worse than colon cancer or breast cancer. It is as bad as pancreatic cancer or brain cancer. And yet it doesn't often get the attention that it needs.

But if we fast-forward the last 20 years, medicine has improved, but yet the two-year survival with the best medicine for the truly advanced heart failure patients, it's still less than 50%. And now with the LVADs, what we're seeing is we can get survival from 50% with the best medicines to above 85% and closer to 90% even. And when you talk about patients have a greater than 95% chance of going home, these are patients that often are stuck in hospital on intravenous medications. There is no home for them. And to have this technology available to us to be able to help these patients get home and get back to their lives, I agree with you, it's completely remarkable.

So now just the final things. For our patients, sometimes they may have already heard about LVADs, they've heard about it from their doctors, they may have heard it from our heart failure doctors here. When would you tell them is the right time for an LVAD? They may be something that they may be thinking about, however, they may still feel pretty good. It's still something they're having trouble wrapping their heads around. So what is your recommendation for our advanced heart failure patients? When is the time to pull the trigger on receiving an LVAD?

Anthony Zaki, MD:

Yeah, that's a great question. Like we talked about earlier, often we're seeing patients with advanced heart failure too late. And so the question becomes at what point should they have considered this technology or should they have been evaluated for this therapy. And so what I would recommend to those patients and to their cardiologist is to get evaluated early, to talk to your local cardiologists and say, "I have heart failure. I've had a few hospitalizations," or, "I'm needing more and more medications to get by. Would an LVAD therapy benefit me?" And we often have these patients come and be evaluated by our team, one of our heart failure cardiologists, one of the surgeons like Dr. Tong or I, and we can evaluate you and we review you. And if we think that it's too early, then at least you're on our radar, and we know about you, and we can follow you with your local cardiologist. But if we think that it's an appropriate time to implant the device and you would benefit from that therapy, then we can go ahead and move forward. So what I would recommend is get the conversation going, know that the therapy exists and it's never too early to get evaluated.

Michael Tong, MD:

Yeah, I completely agree. And often when patients do come to us, we try to exhaust every treatment option for them before we eventually move to an LVAD or a transplant. And one thing that I do notice is when patients start getting hospital admissions for advanced heart failure because they're fluid overloaded and they have to be put on heart failure medications and intravenous medications for their hearts, this is really at that point becomes a revolving door for them. Typically, what I've seen is patients who've been admitted for heart failure more than twice in the past 12 months, this truly is the time because it just shows how quickly they are sliding. And although we may be able to rescue them with the medications, it becomes harder and harder. And we don't want to miss that boat, like you said.

This is fantastic. It's been an honor to continue to work with you every day, and we have a fantastic team of providers, cardiologists, surgeons, and we all work together for patients and not just for the episode of care, but truly for the rest of your life. And we encourage you to have that conversation early with your cardiologist at home or with one of our cardiologists here, and we look forward to taking care of you in the future. So I want to thank you again, Dr. Zaki. I'm Dr. Tong, and it's been an absolute pleasure. Thank you very much. Thank you.

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