Left Ventricular Assist Device (LVAD) Versus Guideline Recommended Medical Therapy in Ambulatory Advanced Heart Failure Patients (GDMT)
Overview
- Phase
- N/A
- Intervention
- Not specified
- Conditions
- End-stage Heart Failure
- Sponsor
- Hospices Civils de Lyon
- Enrollment
- 92
- Locations
- 8
- Primary Endpoint
- All-cause mortality rate
- Status
- Recruiting
- Last Updated
- last year
Overview
Brief Summary
Heart failure is a severe disease affecting approximately 1-2% of the adult population in developed countries and around 26 million people worldwide. Up to 10% of these patients are in advanced stage heart failure, which is defined by a significant morbimortality and considerable medical expenses. Despite advances in its medical management, advanced (or end stage) heart failure is characterized by refractoriness to conventional therapies including guideline-directed pharmacological and non-surgical device treatments. These patients remain severely symptomatic (NYHA IV) and have objective signs of congestion or low cardiac output.
Left ventricular assist devices (LVADs) have been used in patients with heart failure with reduced ejection fraction for almost 20 years either as an alternative or a bridge to heart transplantation. LVADs improve heart failure symptoms and survival at the cost of increased rates of infection, stroke and bleeding.
Despite the lack of evidence, LVAD implantation in ambulatory patients is not rare, with INTERMACS profiles ≥4 patients representing 15.7% of the overall population implanted between 2012 and 2016.
The aim of this study is to investigate the efficacy and safety of left ventricular assist devices compared to traditional HF medical treatment alone in a population of ambulatory advanced heart failure patients. Secondary objectives are to better identify subgroups of patients that would benefit the most from the implantation of an LVAD as well as to assess the optimal timing of intervention.
Investigators
Eligibility Criteria
Inclusion Criteria
- •All patients ≥18 years,
- •End-stage heart failure, evaluated by the local Heart Team, defined as:
- •Left ventricular ejection fraction ≤ 35% within 1 week prior to randomization and
- •Cardiac Index \< 2.2 L/min/m² by hemodynamic use within 1 month prior to randomization or VO2 max \< 14 ml/kg/min (or \<50% of predicted VO2max) within 1 month prior to randomization OR low 6-min walking test (\< 420 m) within 1 month prior to randomization or ≥ 2 hospitalizations for heart failure in the past year and
- •NYHA III-IV (INTERMACS profile 4-6) and and
- •Receiving medical management with optimal doses of betablockers, Angiotensin-Converting-Enzyme-inhibitors or Angiotensin II Receptor Blockers or angiotensin receptor neprilysin inhibitor (if eligible) and Mineralocorticoid Receptor Antagonists and Sodium-GLucose co-Transporter-2 (SGLT2) inhibitors for at least 45 days if tolerated according to guideline at maximal tolerated dose (if maximal HF drug dosage is not reached the investigators will have to explain reason behind not maximal dosage).
- •Receiving Cardiac Resynchronization Therapy and or Implantable Cardioverter Defibrillators if indicated for at least 45 days and
- •No mechanical circulatory support or inotrope therapy since \> 30 days,
- •Having a health coverage,
- •Signed written informed consent,
Exclusion Criteria
- •Inotrope dependent patients or existence of ongoing mechanical circulatory support (MCS) in the last 30 days,
- •Right ventricular dysfunction (heart team consensus) with the expected need of Bi-VAD support,
- •Female patients currently pregnant or women of childbearing age who were not using contraception,
- •Active infection,
- •Irreversible end-organ dysfunction prior to LVAD implantation,
- •Contraindication to anti-coagulant or anti-platelet therapies,
- •History of any organ transplant prior to inclusion,
- •Psychiatric disease/disorder, irreversible cognitive dysfunction or psychosocial issues likely to impair compliance,
- •Frailty according to heart team,
- •Platelet count \< 100,000 x 103/liter (\<100,000/ml)
Outcomes
Primary Outcomes
All-cause mortality rate
Time Frame: Through 24 months when the last subject completes 12 months of follow-up
The composite of 5 clinical endpoints is using a win ratio concept. Mortality has higher priority than Urgent ECMO implantation, urgent heart transplantation or LVAD implantation, unplanned hospitalization for heart failure, improvement of KCCQ by at least 5points, improvement of 6-minute walk test distance by at least 75 meters. Our main approach uses matched pairs of patients. Each pair is 'untied' first on the basis of the most important event (death) and secondly (if necessary) on the lesser event. The numbers of pairs in which the patient on new treatment 'won' and 'lost' are compared to produce the 'win ratio'. The 95% CI and P-value for the win ratio are readily obtained.
Number of unplanned hospitalization for heart failure
Time Frame: Through 24 months when the last subject completes 12 months of follow-up
The composite of 5 clinical endpoints is using a win ratio concept. Mortality has higher priority than Urgent ECMO implantation, urgent heart transplantation or LVAD implantation, unplanned hospitalization for heart failure, improvement of KCCQ by at least 5points, improvement of 6-minute walk test distance by at least 75 meters. Our main approach uses matched pairs of patients. Each pair is 'untied' first on the basis of the most important event (death) and secondly (if necessary) on the lesser event. The numbers of pairs in which the patient on new treatment 'won' and 'lost' are compared to produce the 'win ratio'. The 95% CI and P-value for the win ratio are readily obtained.
Number of urgent ECMO implantation
Time Frame: Through 24 months when the last subject completes 12 months of follow-up
The composite of 5 clinical endpoints is using a win ratio concept. Mortality has higher priority than Urgent ECMO implantation, urgent heart transplantation or LVAD implantation, unplanned hospitalization for heart failure, improvement of KCCQ by at least 5points, improvement of 6-minute walk test distance by at least 75 meters. Our main approach uses matched pairs of patients. Each pair is 'untied' first on the basis of the most important event (death) and secondly (if necessary) on the lesser event. The numbers of pairs in which the patient on new treatment 'won' and 'lost' are compared to produce the 'win ratio'. The 95% CI and P-value for the win ratio are readily obtained.
Number of LVAD implantation
Time Frame: Through 24 months when the last subject completes 12 months of follow-up
The composite of 5 clinical endpoints is using a win ratio concept. Mortality has higher priority than Urgent ECMO implantation, urgent heart transplantation or LVAD implantation, unplanned hospitalization for heart failure, improvement of KCCQ by at least 5points, improvement of 6-minute walk test distance by at least 75 meters. Our main approach uses matched pairs of patients. Each pair is 'untied' first on the basis of the most important event (death) and secondly (if necessary) on the lesser event. The numbers of pairs in which the patient on new treatment 'won' and 'lost' are compared to produce the 'win ratio'. The 95% CI and P-value for the win ratio are readily obtained.
Number of urgent heart transplantation
Time Frame: Through 24 months when the last subject completes 12 months of follow-up
The composite of 5 clinical endpoints is using a win ratio concept. Mortality has higher priority than Urgent ECMO implantation, urgent heart transplantation or LVAD implantation, unplanned hospitalization for heart failure, improvement of KCCQ by at least 5points, improvement of 6-minute walk test distance by at least 75 meters. Our main approach uses matched pairs of patients. Each pair is 'untied' first on the basis of the most important event (death) and secondly (if necessary) on the lesser event. The numbers of pairs in which the patient on new treatment 'won' and 'lost' are compared to produce the 'win ratio'. The 95% CI and P-value for the win ratio are readily obtained.
Distance in meters at 6-min walking test
Time Frame: Through 24 months when the last subject completes 12 months of follow-up
The composite of 5 clinical endpoints is using a win ratio concept. Mortality has higher priority than Urgent ECMO implantation, urgent heart transplantation or LVAD implantation, unplanned hospitalization for heart failure, improvement of KCCQ by at least 5points, improvement of 6-minute walk test distance by at least 75 meters. Our main approach uses matched pairs of patients. Each pair is 'untied' first on the basis of the most important event (death) and secondly (if necessary) on the lesser event. The numbers of pairs in which the patient on new treatment 'won' and 'lost' are compared to produce the 'win ratio'. The 95% CI and P-value for the win ratio are readily obtained.
Quality of life assessed by KCCQ score
Time Frame: Through 24 months when the last subject completes 12 months of follow-up
The composite of 5 clinical endpoints is using a win ratio concept. Mortality has higher priority than Urgent ECMO implantation, urgent heart transplantation or LVAD implantation, unplanned hospitalization for heart failure, improvement of KCCQ by at least 5points, improvement of 6-minute walk test distance by at least 75 meters. Our main approach uses matched pairs of patients. Each pair is 'untied' first on the basis of the most important event (death) and secondly (if necessary) on the lesser event. The numbers of pairs in which the patient on new treatment 'won' and 'lost' are compared to produce the 'win ratio'. The 95% CI and P-value for the win ratio are readily obtained.
Secondary Outcomes
- All-cause mortality rate(at 24 months)
- number of ECMO implantation(at 24 months)
- Number of patients with a persistence of the eligibility to LVAD implantation(at 12 months)
- Distance in meters at 6-min walking test(at 24 months)
- Quality of life assessed by European Quality of Life-5 Dimensions (EQ-5D) questionnaire score(at 24 months)
- New York Heart Association (NYHA) status(at 24 months)
- Quality of life assessed by KCCQ score(at 24 months)
- number of urgent heart transplantation(at 24 months)
- Unplanned hospitalization for heart failure rate(at 24 months)
- Recurrent hospitalizations rate(at 24 months)
- Heart failure assessed by N Terminal Pro-Brain Natriuretic Peptide (NT-proBNP) rate(at 24 months)
- Number of adverse events (AEs)(at 24 months)
- Number of days alive out of hospital(at 24 months)
- Cardio-renal syndrome assessed by rates of Soluble urokinase-type Plasminogen Activator Receptor (SuPAR)(at 24 months)
- Cardio-renal syndrome assessed by rates of Kidney Injury Molecule-1 (KIM1)(at 24 months)
- VAD implantation rate(at 24 months)
- Right ventricular function assessed by echocardiographic parameters(at 24 months)
- Cardio-renal syndrome assessed by rates of Interleukin-6 (IL-6)(at 24 months)