For most patients with heart failure, their condition tends to get worse over time. With severe heart failure where medications are no longer effective, a heart transplant would be the only option.
Heart Failure, also known as congestive heart failure, is a serious condition where the heart loses its ability to pump enough blood to the rest of the body, leaving the organs and tissues with insufficient oxygen and nutrients to function properly. The symptoms include shortness of breath even at rest, breathing difficulties, swollen ankles, legs or abdomen, tiredness, and so on. Once diagnosed, patients usually require lifetime medication and lifestyle modification, as well as procedures and/or surgeries.
When heart failure worsens
For most patients with heart failure, their condition tends to get worse over time. With severe heart failure where medications are no longer effective, patients might require frequent and multiple hospital admissions, due to deteriorating kidney and liver functions. These patients would experience persistent difficulties in breathing and have a very poor quality of life.
Images taken from Abbott’s Understanding The Heartmate 3 LVAD System’ Poster: The LVAD is an egg-sized mechanical pump that draws blood from the left ventricle and then pumps it into the aorta. An electrical driveline exits from the upper abdomen to obtain electrical power from a controller and two batteries. The pump must always be plugged into batteries or an electrical wall outlet, which means the patient must bring or wear the batteries at all times.
For such patients, a heart transplant would be the only option. However, a heart transplant does not happen immediately. Besides having to meet conditions such as age – only younger patients aged 60 years old and below are eligible, the number of donors in Singapore is limited too. When an available heart comes along, it also has to be assessed for suitability to the patient for a match to happen.
An artificial heart to keep on living
In 2008, an alternative treatment option was made available – the Left Ventricular Assist Device (LVAD) – a mechanical heart implant to take over the functions of the heart. The LVAD is known to be a bridge to transplant, or may also be a lifelong treatment known as destination therapy for those who cannot get a heart transplant. While waiting for a heart transplant, the LVAD helps to pump blood around the body.
Process of getting an LVAD
Patients need to undergo an open-heart surgery to have the LVAD implantation. After surgery, patients typically require to stay in the hospital for a few weeks, or longer if necessary. Before discharge, patients and their caregivers are required to learn how to use the device and care for the patient.
Living with LVAD
Immediately after getting an LVAD, patients will usually feel vast improvements in their heart failure symptoms – lesser breathlessness and swelling, and more energy1. While it takes time to get used to having a device in the body, most patients adjust well within a few months and can return to school or work.
In the last decade since 2009, NHCS has implanted the LVAD in some 132 patients, with 92% and 68% survival rates at three months and five years, respectively. These patients have also been observed to be able to walk more than 400 metres on average for their 6-minute walk test, six months after their surgery, which was a huge improvement compared to pre-surgery.
Mr Timothy Quah, a patient of NHCS, proudly wears a custom-made vest containing his LVAD batteries.
Living with a device 24/7 also means that patients would need to have a constant power source, to be on long-term medications and to perform daily dressing to the device’s driveline. However, there are ways to overcome some of these inconveniences in exchange for a better quality of life. Patients can carry the battery and controller in a pouch, sling bag or even fashionable vests! The LVAD is also a quiet machine and does not ‘disturb’ the patient as they go about their daily lives.
For avid travellers, extra batteries and charger must be carried along – though it may be slightly inconvenient, it can be managed with proper planning. Sexual activity is not an issue although female patients are advised to use contraceptives as pregnancy will be hazardous to their health condition.
Studies show that patients with LVAD usually live longer than those without. Nearly 90% of patients with LVAD are still alive after one year1-4, whilst those without LVAD, especially those severely ill, usually do not survive as long1.
Complications of LVAD
Like in any procedure and surgery, there are also risks in LVAD. Studies showed that patients with LVAD may encounter the following one year after surgery
1-3:
5 to 6 patients out of 10 are readmitted to the hospital
- 1 in 10 has a stroke
- 2 in 10 develop a device-related infection such as pump thrombosis or have a serious bleed requiring medical care
- 3 in 10 have ongoing heart failure
Other less serious complications include superficial driveline infection, feelings of depression and equipment malfunction.
LVADs continue to be an excellent option for patients with advanced heart failure, with most experiencing dramatic improvements in their daily lives.
As medical technology advances, LVAD is contributing to longer survival rates. The average waiting time for a heart transplant in Singapore has increased from 153 days, before LVAD was available, to presently 1,172 days (slightly more than three years) for LVAD patients. The majority of these patients are likely to live with their LVAD for the rest of their lives.
1. McIlvennan CK, Magid KH, Ambardekar AV, Thompson JS, Matlock DD, Allen LA. Clinical Outcomes Following Continuous-Flow Left Ventricular Assist Device: A Systematic Review. Circ. Heart Fail. 2014;7(6):1003-13.
2. Mehra MR, Uriel N, Naka Y, et al. A fully magnetically levitated left ventricular assist device - final report. N Engl J Med. 2019;380(17):1618-1627.
3. Mehra MR, Cleveland JC, Uriel N, et al. Primary results of long-term outcomes in the MOMENTIM 3 pivotal trial and continued access protocol study phase: a study of 22000 HeartMate 3 left ventricular assist device implants. Eur J Heart Fail. 2021.
4. Kormos RL, Cowger J, Pagani FD, et al. The Society of Thoracic Surgeons Intermacs Database annual report: evolving indications, outcomes, and scientific partnerships. J Heart Lung Transplant. 2019;38(2):114-126.
5. Yu S, Cevasco M, Sanchez J, et al. Considerations for Referral: What Happens to Patients after Being Turned Down for Left Ventricular Assist Device Therapy. J Card Fail. 2020;26(4):300-307
This article is from Murmurs Issue 44 (September – December 2022). Click here to read other articles or issues.
