timing of IV inotrope therapy and LVAD placement

[casey444]

My husband's cardiologist has recommended an LVAD as bridge to heart transplant.  Husband is class III/IV but relatively young at age 56 (CHF due to left ventrical noncompaction, probably a congenital defect).  Not yet approved, but hospital is now suggesting several months of IV inotrope therapy and waiting several months to have insertion done at this hospital rather than another.  (Present hospital not yet certified by our insurance.)  If approved, is the LVAD better done now than later?  Or will waiting a few months make a difference?  We're afraid he'll take a sudden turn for the worse as he progressed from class 1 to this level in three months.

[Navin Rajagopalan, MD]

Hello,

I hope your husband is still doing well.

LVAD technology is certainly an exciting development in the field of heart failure.  Unfortunately, severe heart failure continues to become more common, but for those who need it, the number of heart transplants is limited by the number of donors available.  LVAD placement allows more patients to recover from heart failure and also has the advantage of being able to help patients who are “too sick” to wait for a transplant.  

As another poster mentioned, there are limitations with LVAD technology.  Patients are required to wear a controller and batteries to help power the device.  However, for those patients who feel better with an LVAD, this is a minor convenience.  My suggestion would be to try and talk to patients who have an LVAD and to see firsthand how they are coping with the device.  I have several patients who are being supported with LVADs and they are the best advocates for the procedure.  In several cases, patients who were unsure about undergoing surgery were more comfortable with the decision to proceed after talking with a patient who already had an LVAD implanted.  

As you stated, there may be some risk with waiting too long for surgery.  Needing outpatient inotropic therapy is a sign that the heart is fairly weak.  Certainly, if the LVAD is being considered as a bridge to transplant, it may be reasonable to ask your husband’s physicians if he can be listed for transplant soon and undergo LVAD placement if a donor does not become available in a reasonable time period.  These are complicated issues that you will likely need to discuss with your husband’s physicians.

If you need any additional information/questions, feel free to ask.  

Navin Rajagopalan, MD

[gmachris518]

Marketing of the newest technologies most likely does play a major role in what is offered to patients.

Years ago the hysterectomy was real popular and many women had them, then later found out it wasn't necessary.

Have you seen the new heart pump on the market?  It has two battery packs that hang on each side of the patient, on their belt, then a controller that hangs on the front of the belt.  From the controller, there is a soft wire that goes to the pump, which is directly attached to the heart.  They sing it's praises, and talk about how much better the recipients of this new device feel, even though they are carrying around several pounds of hardware to feel better.  I guess it's better than death, but still, when you don't feel good, who wants to be transformed into a packhorse?

The newest kidney treatment, on the market, is peritineal, which uses a soft rubber tube that goes into the stomach area, and fills the body cavity with dialysate, which supposedly does the same thing as dialysis, which pulls all of the impurities out of the blood.  However, the amount of fluid a patient has to wear in their body cavity, and change several times a day, weighs 6 pounds, not to mention the rubber hose that hangs from their abdomen 24/7.  They tried to sell me on this newest treatment when I entered stage 5 kidney failure, using the argument that I would simply feel pregnant, 24/7.  I told them "no thank you", and I went with home hemo-dialysis, and even though it takes 5 hours out of each of my days, I'm satified with my choice.  

I'm telling you this, because you really want to weigh the options, and make sure your husband can be happy with his choice.  Read everything you can get your hands on, about the treatment they are offering, and know everything you can possibly find about it,before you jump in with both feet.  If I hadn't done that, I would be stuck with a belly full of fluid for the rest of my life, and as a woman, that would just be awful, from my point of view.

I hope the best for your husband and you.  Keep us posted on here, ok?

[casey444]

Thanks, that was my thought as well.  I think there's a lot of marketing and competition in the newer technologies and, while I hate to say it, sometimes I think that plays a part in the recommendations.  Not so much from our doctors, but from hospital staff.  Just trying to weed through it all.

[gmachris518]

I would say sooner is better than later, as the heart is as predictable as the weather, and no one can tell you what will happen within a few months, especially with his progression within three months, not even a specialist can predict what will happen in your husband's case.