Section of Advanced Heart Failure and Transplantation, Division of Cardiology, Department of Medicine; Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA.
Division of Cardiac Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA.
J Heart Lung Transplant. 2019 Apr;38(4):374-381. doi: 10.1016/j.healun.2018.12.008. Epub 2018 Dec 15.
Trial and registry data have reported mortality rates and causes of death in patients with left ventricular assist devices (LVADs); however, a more granular description is needed of end of life, including location of death and quality of life (QOL), to better guide expectations and care.
To identify where patients with an LVAD died, characterize QOL before death, and cause of death over time, we evaluated patients in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) implanted with a continuous-flow LVAD.
From 18,733 patients implanted with an LVAD during the period 2008 to 2016, 4,916 patients were known to have died, of whom 98% had a recorded location of death. Overall, 76.9% died in the hospital, with progressively more patients dying outside of the hospital further post-LVAD implant: <1 month, 2.3%; 1 to 12 months, and 16.8%; and >12 months, 37.4%. In a multivariable analysis, increased age (RR (risk ratio) 1.06, 95% confidence interval [CI] 1.02 to 1.12, p = 0.01) and destination therapy indication (RR 1.15, 95% CI 1.03 to 1.28, p = 0.01) increased the likelihood of dying outside the hospital. Comparing 3 months post-implant with 6 months before death in a subset of patients, QOL remained clinically stable (EQ-5D Visual Analog Scale [mean ± SD]: 68.3 ± 22.2 to 66.7 ± 21.7, p = 0.11; KCCQ: 61.0 ± 22.2 to 57.8 ± 23.2, p = 0.003). The most common cause of death <1 month post-implant was multiple-organ failure (20.4%) and at >1 month post-implant it was neurologic dysfunction (28.2%).
Most patients with an LVAD died in the hospital. QOL remained stable months before death and causes of death were varied, but increasingly dominated by stroke. By understanding death with an LVAD in place, clinicians are in a better position to educate patients and caregivers about what to expect and provide to support tailored to patient and caregiver needs.
临床试验和注册数据报告了左心室辅助装置（LVAD）患者的死亡率和死亡原因；然而，为了更好地指导预期和护理，需要更详细地描述生命末期的情况，包括死亡地点和生活质量（QOL）。
为了确定接受 LVAD 植入的患者的死亡地点，描述死亡前的 QOL，并随着时间的推移描述死亡原因，我们评估了 2008 年至 2016 年期间接受 INTERMACS（机械循环支持机构间注册）植入连续流 LVAD 的患者。
在接受 LVAD 植入的 18733 名患者中，有 4916 名患者已知死亡，其中 98%有记录的死亡地点。总体而言，76.9%的患者在医院死亡，随着 LVAD 植入后时间的推移，越来越多的患者在医院外死亡：<1 个月，2.3%；1 至 12 个月，16.8%；>12 个月，37.4%。多变量分析显示，年龄增加（RR（风险比）1.06，95%置信区间[CI]1.02 至 1.12，p=0.01）和终末期治疗指征（RR 1.15，95%CI 1.03 至 1.28，p=0.01）增加了医院外死亡的可能性。在一组患者中，比较植入后 3 个月与死亡前 6 个月的 QOL，发现 QOL 保持临床稳定（EQ-5D 视觉模拟量表[均值±标准差]：68.3±22.2 至 66.7±21.7，p=0.11；KCCQ：61.0±22.2 至 57.8±23.2，p=0.003）。植入后<1 个月最常见的死亡原因是多器官衰竭（20.4%），植入后>1 个月最常见的死亡原因为神经功能障碍（28.2%）。
大多数接受 LVAD 植入的患者在医院死亡。QOL 在死亡前数月保持稳定，死亡原因多种多样，但越来越多地由中风主导。通过了解 LVAD 植入后的死亡情况，临床医生能够更好地教育患者和护理人员，让他们了解预期的情况，并提供满足患者和护理人员需求的支持。
