Incidence and predictors of cognitive decline in patients with left ventricular assist devices.
BACKGROUND
After left ventricular assist device (LVAD) placement for advanced heart failure, increased cerebral perfusion should result in improved cognitive function. However, stroke (a well-known LVAD complication) and subclinical cerebral ischemia may result in transient or permanent cognitive decline. We sought to describe the incidence and predictors of cognitive decline after LVAD using a valid, sensitive assessment tool.


RESULTS
Among 4419 patients in the Interagency Registry for Mechanically Assisted Circulatory Support who underwent LVAD implantation between May 2012 and December 2013, cognitive function was assessed in 1173 patients with the Trail Making B Test before LVAD and at 3, 6, and 12 months. The test detects several forms of cognitive impairment, including subclinical stroke. Cognitive decline was defined as a clinically important increase during follow-up using a moderate Cohen d effect size of 0.5×baseline SD (32 s). The cumulative incidence of cognitive decline in the year after LVAD implantation, treating death and transplantation as competing risks, was 29.2%. In adjusted analysis, older age (≥70 versus <50 years; hazard ratio, 2.24; 95% confidence interval 1.46-3.44; P(trend)<0.001) and destination therapy (hazard ratio, 1.42; 95% confidence interval, 1.05-1.92) were significantly associated with greater risk of cognitive decline.


CONCLUSIONS
Cognitive decline occurs commonly in patients in the year after LVAD and is associated with older age and destination therapy. These results could have important implications for patient selection and improved communication of risks before LVAD implantation. Additional studies are needed to explore the association between cognitive decline and subsequent stroke, health status, and mortality in patients after LVAD.
From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.). fendlert@umkc.edu.
Timothy J
TJ
Fendler
From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.).
John A
JA
Spertus
From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.).
Kensey L
KL
Gosch
From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.).
Philip G
PG
Jones
From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.).
Jared M
JM
Bruce
From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.).
Michael E
ME
Nassif
From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.).
Kelsey M
KM
Flint
From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.).
Shannon M
SM
Dunlay
From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.).
Larry A
LA
Allen
From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.).
Suzanne V
SV
Arnold
D000368:Aged; D003072:Cognition Disorders / Q000453:epidemiology* / Q000209:etiology; D005260:Female; D006353:Heart-Assist Devices / Q000009:adverse effects*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012042:Registries; D014481:United States / Q000453:epidemiology
brain ischemia; heart-assist devices; mild cognitive impairment