The dilemma of a left ventricular assist device explantation: a decision analysis.
BACKGROUND
Left ventricular assist devices (LVADs) are an important adjunct to the management of end-stage heart failure patients. Uncertainty remains regarding whether to remove an LVAD in a clinically stable, asymptomatic patient who displays signs of ventricular recovery.


OBJECTIVE
To evaluate, from a patient's perspective, the quality-adjusted life expectancy of an LVAD explantation.


METHODS
A Markov state transition model was used to assess the benefits of two strategies: remove an LVAD or continue the LVAD support. Effectiveness was measured in quality-adjusted life months. Utility and probability scores were derived from the literature and expert opinion. The base case focused on a 35-year-old man with dilated cardiomyopathy, an implantable LVAD and signs of ventricular recovery, with New York Heart Association class I heart failure symptoms.


RESULTS
In the base case, continuing LVAD support was strongly preferred and improved quality-adjusted life expectancy by nine quality-adjusted life months. In sensitivity analyses for the utility post-transplant, removal of the device would have been preferred if the utility was less than 0.7. The model was also sensitive to the probability of late complications post-LVAD implantation. As the probability of complications increased (greater than 28%), the preferred strategy was to remove the LVAD.


CONCLUSIONS
Continuing LVAD support in asymptomatic patients with signs of ventricular recovery appears to be the preferred strategy for conveying greater quality-adjusted life months compared with LVAD explantation. As the probability of complications after LVAD implantation increases, the preferred strategy is to remove the LVAD.
Delgado
Diego H
DH
Division of Cardiology and Transplantation, Toronto General Hospital, Toronto, Canada. diego.delgado@uhn.on.ca
Ross
Heather J
HJ
Rao
Vivek
V
D000328:Adult; D009202:Cardiomyopathies / Q000628:therapy*; D003661:Decision Support Techniques; D006333:Heart Failure / Q000401:mortality / Q000628:therapy*; D006352:Heart Ventricles / Q000473:pathology*; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008390:Markov Chains; D015233:Models, Statistical; D011336:Probability; D019057:Quality-Adjusted Life Years; D016019:Survival Analysis