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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.
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.
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.
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.
Studies show that many patients with severe heart failure do not live past a year1,5. However, opting not to have an LVAD means that the patients do not have to depend on a machine to live, and they can leave the hospital earlier to spend theirremaining time at home. They may also need to receive palliative care or hospice service sooner than expected.Palliative careWith or without an LVAD, palliative care offers medical care for those with serious illnesses and can help in relieving symptoms, pain and stress. It also provides emotional and spiritual support, enhancing the overall quality of life for patients and their caregivers.HospiceHospice care is for patients near the end of their lives. The care is provided by doctors, nurses, and other health professionals, which includes medical, emotional, and spiritual support, and helps to provide comfort and peace for patients. It usually occurs at a patient’s home, or can also occur in other places such as a nursing home.
5 to 6 patients out of 10 are readmitted to the hospital
Other less serious complications include superficial driveline infection, feelings of depression and equipment malfunction.
In the first few months after surgery, the responsibilities of LVAD caregivers typically involve helping with the daily dressing of the driveline site, caring for batteries and equipment, managing medicines, assisting the patients with sponge bathing, meals, and accompanying for medical appointments and so on. The caregiver may feel overwhelmed and stressed initially, although the level of care required usually lessens over time once the patient gains independence.
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