E. Montgomery

The Prevalence and Prognostic Significance of Frailty in Patients With Advanced Heart Failure Referred for Heart Transplantation.

Background Frailty is a clinically recognized syndrome of decreased physiological reserve. The heightened state of vulnerability in these patients confers a greater risk of adverse outcomes after even minor stressors. Our aim was to assess the prevalence and prognostic significance of the frailty phenotype in patients referred for heart transplantation. Methods Consecutive patients referred or on the waiting list for heart transplantation from March 2013 underwent frailty assessment. Frailty was defined as a positive response to 3 or more of the following 5 components: weak grip strength, slowed walking speed, poor appetite, physical inactivity, and exhaustion. In addition, markers of disease severity were obtained, and all patients underwent cognitive (Montreal Cognitive Assessment) and depression (Depression in Medical Illness-10) screening. Results One hundred twenty patients (83 men:37 women; age, 53 ± 12 years, range, 16-73 years; left ventricular ejection fraction, 27 ± 14%) underwent frailty assessment. Thirty-nine of 120 patients (33%) were assessed as frail. Frailty was associated with New York Heart Association class IV heart failure, lower body mass index, elevated intracardiac filling pressures, lower cardiac index, anemia, hypoalbuminemia, hyperbilirubinemia, cognitive impairment, and depression (all &rgr; < 0.05). Frailty was independent of age, sex, heart failure duration, left ventricular ejection fraction, or renal function. Frailty was an independent predictor of increased all-cause mortality: 1 year actuarial survival was 79 ± 5% in the nonfrail group compared with only 54 ± 9% for the frail group (P < 0.005). Conclusions Frailty is prevalent among patients with advanced symptomatic heart failure referred for heart transplantation and is associated with increased mortality.

Reversibility of Frailty After Bridge-to-Transplant Ventricular Assist Device Implantation or Heart Transplantation.

Background We recently reported that frailty is independently predictive of increased mortality in patients with advanced heart failure referred for heart transplantation (HTx). The aim of this study was to assess the impact of frailty on short-term outcomes after bridge-to-transplant ventricular assist device (BTT-VAD) implantation and/or HTx and to determine if frailty is reversible after these procedures. Methods Between August 2013 and August 2016, 100 of 126 consecutive patients underwent frailty assessment using Fried’s Frailty Phenotype before surgical intervention: 40 (21 nonfrail, 19 frail) BTT-VAD and 77 (60 nonfrail, 17 frail) HTx—including 17 of the 40 BTT-VAD supported patients. Postprocedural survival, intubation time, intensive care unit, and hospital length of stay were compared between frail and nonfrail groups. Twenty-six frail patients were reassessed at 2 months or longer postintervention. Results Frail patients had lower survival (63 ± 10% vs 94 ± 3% at 1 year, P = 0.012) and experienced significantly longer intensive care unit (11 vs 5 days, P = 0.002) and hospital (49 vs 25 days, P = 0.003) length of stay after surgical intervention compared with nonfrail patients. Twelve of 13 frail patients improved their frailty score after VAD (4.0 ± 0.8 to 1.4 ± 1.1, P < 0.001) and 12 of 13 frail patients improved their frailty score after HTx (3.2 ± 0.4 to 0.9 ± 0.9, P < 0.001). Handgrip strength and depression improved postintervention. Only a slight improvement in cognitive function was seen postintervention. Conclusions Frail patients with advanced heart failure experience increased mortality and morbidity after surgical intervention with BTT-VAD or HTx. Among those who survive frailty is partly or completely reversible underscoring the importance of considering this factor as a dynamic not fixed entity.

Frailty Predicts Mortality after Heart Transplantation

Background We have previously reported that combining cognitive assessment with the Fried frailty phenotype (FFP) enhances mortality prediction in advanced heart failure (AHF) patients referred for VAD or heart transplant (HTx) assessment (J Heart Lung Transplant 2016;35:1092-100). In this study, we examined the impact of frailty on post-HTx outcomes. Methods Ninety-six patients (53 men; 43 women) who underwent assessment of cognition and frailty within 12 months of HTx between 2013 and 2017 were included in the study. Frailty was defined as > 3 physical domains of the Fried Frailty Phenotype (FFP) or > 2 physical domains of the FFP plus cognitive impairment defined as a score of < 26/30 on the Montreal Cognitive Assessment (MoCA). Depression screening was also performed using the Depression in Medical Illness (DMI-10) score. Results Average time between frailty assessment and HTx was 4.5 + 3.1 months. Thirty were classified as frail (F), and 66 were not frail (NF). There was no significant difference in age (48.2±14 F vs 50.6±15, p=0.46), or BMI (24.9±5.5 vs 24.8±4.2, p=0.92) between groups, but a higher proportion of women than men were frail (42% vs 23%, p < 0.05). Pre-transplant mechanical support was utilised in a similar proportion of F (n=8/30) and NF (n=12/66) patients (p = 0.34). As expected, mean MoCA scores were lower in the F group (24 ± 4 vs 26 ± 3, p=0.0037). Depression as defined by a DMI score > 9 was also more common in the F group (53% vs 26%, p = 0.01). Frailty was an independent predictor of all-cause mortality after HTx with 1 yr survival 74 + 9% in the F group, compared to 98 + 2% in the NF group (p = 0.0003). There were trends towards longer median intubation times, ICU and hospital length of stay in the F group but differences were not significant. Conclusions Similar to our previous finding that frailty was an independent predictor of mortality in AHF patients referred for HTx assessment, frailty was also an independent predictor of mortality after HTx. These findings may help us better identify patients who will benefit most from transplant. NHMRC Program Grant 1074386.

Reversibility of Frailty After Lung Transplantation

Background. Frailty contributes to increased morbidity and mortality in patients referred for and undergoing lung transplantation (LTX). &e study aim was to determine if frailty is reversible after LTX in those classified as frail at LTX evaluation. Methods. Consecutive LTX recipients were included. All patients underwent modified physical frailty assessment during LTX evaluation. For patients assessed as frail, frailty was reassessed on completion of the post-LTX rehabilitation program. Frailty was defined by the presence of ≥ 3 domains of the modified Fried Frailty Phenotype (mFFP). Results. We performed 166 lung transplants (frail patients, n� 27, 16%). Eighteen of the 27 frail patients have undergone frailty reassessment. Eight frail patients died, and one interstate recipient did not return for reassessment. In the 18 (66%) patients reassessed, there was an overall reduction in their frailty score post-LTX ((3.4± 0.6 to 1.0± 0.7), p< 0.001) with 17/18 (94%) no longer classified as frail. Improvements were seen in the following frailty domains: exhaustion, mobility, appetite, and activity. Handgrip strength did not improve posttransplant. Conclusions. Physical frailty was largely reversible following LTX, underscoring the importance of considering frailty a dynamic, not a fixed, entity. Further work is needed to identify those patients whose frailty is modifiable and establish specific interventions to improve frailty.