Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Ambulatory Heart Failure Patients: Results From the ROADMAP Study.
BACKGROUND
Data for left ventricular assist devices (LVADs) in patients with noninotrope-dependent heart failure (HF) are limited.


OBJECTIVE
The goal of this study was to evaluate HeartMate II (HMII) LVAD support versus optimal medical management (OMM) in ambulatory New York Heart Association functional class IIIB/IV patients meeting indications for LVAD destination therapy but not dependent on intravenous inotropic support.


METHODS
This was a prospective, multicenter (N = 41), observational study of 200 patients (97 LVAD, 103 OMM). Entry criteria included ≥1 hospitalization for HF in the last 12 months and 6-min walk distance (6MWD) <300 m. The primary composite endpoint was survival on original therapy with improvement in 6MWD ≥75 m at 12 months.


RESULTS
LVAD patients were more severely ill, with more patients classified as Interagency Registry for Mechanically Assisted Circulatory Support profile 4 (65% LVAD vs. 34% OMM; p < 0.001) than 5 to 7. More LVAD patients met the primary endpoint (39% LVAD vs. 21% OMM; odds ratio: 2.4 [95% confidence interval: 1.2 to 4.8]; p = 0.012). On the basis of as-treated analysis, 12-month survival was greater for LVAD versus OMM (80 ± 4% vs. 63 ± 5%; p = 0.022) patients. Adverse events were higher in LVAD patients, at 1.89 events/patient-year (EPPY), primarily driven by bleeding (1.22 EPPY), than with OMM, at 0.83 EPPY, primarily driven by worsening HF (0.68 EPPY). Most patients (80% LVAD vs. 62% OMM; p < 0.001) required hospitalizations. Health-related quality of life (HRQol) and depression improved from baseline more significantly with LVADs than with OMM (Δ visual analog scale: 29 ± 25 vs. 10 ± 22 [p < 0.001]; Δ Patient Health Questionnaire-9: -5 ± 7 vs. -1 ± 5 [p < 0.001]).


CONCLUSIONS
Survival with improved functional status was better with HMII LVAD compared with OMM. Despite experiencing more frequent adverse events, LVAD patients improved more in HRQol and depression. The results support HMII use in functionally limited, noninotrope-dependent HF patients with poor HRQoL. (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device [LVAD] and Medical Management [ROADMAP]; NCT01452802).
Houston Methodist Hospital, Houston, Texas. Electronic address: jestep@houstonmethodist.org.
Jerry D
JD
Estep
Cleveland Clinic, Cleveland, Ohio.
Randall C
RC
Starling
INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma.
Douglas A
DA
Horstmanshof
Duke University, Durham, North Carolina.
Carmelo A
CA
Milano
University of Utah, Salt Lake City, Utah.
Craig H
CH
Selzman
Virginia Commonwealth University, Richmond, Virginia.
Keyur B
KB
Shah
Houston Methodist Hospital, Houston, Texas.
Matthias
M
Loebe
Cleveland Clinic, Cleveland, Ohio.
Nader
N
Moazami
INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma.
James W
JW
Long
University of Utah, Salt Lake City, Utah.
Josef
J
Stehlik
Virginia Commonwealth University, Richmond, Virginia.
Vigneshwar
V
Kasirajan
Abington Memorial Hospital, Abington, Pennsylvania.
Donald C
DC
Haas
Thoratec Corporation, Pleasanton, California.
John B
JB
O'Connell
Piedmont Hospital, Atlanta, Georgia.
Andrew J
AJ
Boyle
Thoratec Corporation, Pleasanton, California.
David J
DJ
Farrar
Duke University, Durham, North Carolina.
Joseph G
JG
Rogers
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D057186:Comparative Effectiveness Research; D005260:Female; D006333:Heart Failure / Q000188:drug therapy / Q000401:mortality / Q000628:therapy*; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011788:Quality of Life; D018570:Risk Assessment; D016896:Treatment Outcome; D055815:Young Adult
HeartMate II; ROADMAP; functional status; quality of life; risk/benefit analysis