By Ronson J. Madathil, MD, FACC, cardiac surgeon and surgical director of the VAD program at WellSpan Health
Ventricular assist devices (VADs) can help patients with advanced heart failure (HF) thrive for years. But many patients who need a VAD don’t get one until their condition has advanced too far for the device to provide much benefit.
The VAD team at WellSpan Health sees dozens of these patients every year. We’re one of the highest-volume centers in Pennsylvania and the surrounding region, with a high proportion of complex cases.
Ronson J. Madathil, MD, FACC
To help us catch patients before it’s too late, referring PCPs and cardiologists must understand the progression of advanced HF symptoms, the value that VADs can provide, and when it’s time to consult an HF specialist. By working together, we can see patients earlier in their disease progression and add length and fulfillment to their lives.
VADs are best before symptoms reach INTERMACS level 2
Timely VAD evaluation depends on knowing how heart failure (HF) progresses and what counts as “too late.” The New York Heart Association has a well-known classification system that defines advanced HF into four broad classes. But this breakdown blurs important nuances in symptom progression.
When I evaluate patients, I use the INTERMACS scale, which classifies advanced HF in more detail:
7 - Symptoms with mild exertion
6 - Symptoms with meaningful activity (e.g., playing with grandkids)
5 - Symptoms with daily activity (e.g., walking)
4 - Symptoms at rest
3 - Stabilized with home inotrope (continuous drip through a PICC line)
2 - Declining with home inotrope
1 - Using a temporary mechanical device
For VADs, the key is to catch patients before they reach level 2. At levels 2 and 1 (so-called “crash and burn” patients), VAD implantation carries a higher risk of complications like stroke and right heart failure, tends to involve longer hospital stays, and is less likely to help patients thrive long-term.
But at level 3 or above, VAD implantation leads to a much smoother (and shorter) clinical course. Organs are less likely to have been chronically damaged by years of heart failure, and patients themselves are in overall better shape for the procedure (e.g., less cardiac cachexia). After they receive the reliable blood flow they need, they are often restored to levels of health and activity they haven’t reached in years.
When to refer to an HF specialist
Every patient with HF should see a heart failure cardiologist who can evaluate them for VADs and other treatments at the right time. Here are steps PCPs and cardiologists can take to ensure patients with HF get the care they need.
Tips for PCPs
Many early signs of HF look like signs of aging — such as swelling in the legs due to water retention or increasing fatigue with exertion. Look beyond these signs to see if referral to an HF cardiologist is warranted.
- Ask patients about their activities of daily living. It’s remarkable how patients can curtail their activities over time without noticing. Patients who say they’re “fine” may reveal more when you dig into details. The Kansas City Cardiomyopathy Questionnaire is a great tool and can help you place patients on the INTERMACS scale. Use some or all the questions, and compare answers over time to gauge the progression of symptoms.
- Order an echocardiogram for borderline cases. For example, make it part of the workup for shortness of breath and/or bilateral lower extremity swelling. An ejection fraction of less than 40% is concerning and warrants a referral. Less than 35% is advanced HF.
Tips for cardiologists
Keep in mind that VADs are no longer strictly a bridge to transplant. Five-year survival rates for current VAD models are nearly equal to those for transplant. VADs are so reliable that having one no longer carries as much weight to move a patient up the transplant list.
Talk to patients about VADs early in their HF journey, even before they reach the stage of advanced HF. Knowing their options helps patients be more open and optimistic if they become a candidate in the future.
Among cardiologists, electrophysiologists (EPs) often provide ongoing care to advanced HF patients after implanting them with defibrillators. If that’s your situation, ask your patients if they’d like to see an HF specialist as well. I coordinate care with many EPs, which enables each of us to focus on our specialties and ensures the patient gets the best of both worlds.
Extra steps we’re taking to support timely VAD evaluation
My team is helping providers recognize and refer VAD candidates earlier in their disease progression. We’ve implemented automated software that flags the medical record of patients with low ejection fraction and other advanced HF risk factors. As a result, providers have referred close to 100 patients to us who weren’t previously seeing an HF specialist. When patients with risk factors come through a WellSpan Health ED or other clinic, the software will automatically send letters to them and their providers explaining our findings and offering to connect with our HF team.
Patients in the VAD program receive exceptional care and support, including daily monitoring of health metrics and hands-on attention from our dedicated social worker. Our program is accredited by the Joint Commission and has recently obtained DNV certification as well. For referrals, we believe strongly in the “shared care” model where we partner with the patient and their existing providers.
For more information about the WellSpan VAD program or to refer a patient, contact Dr. Madathil at rmadathil@wellspan.org.