Frailty in the End-Stage Lung Disease or Heart Failure Patient: Implications for the Perioperative Transplant Clinician

Abstract

The syndrome of frailty for patients undergoing heart or lung transplantation has been a recent focus for perioperative clinicians because of its association with postoperative complications and poor outcomes. Patients with end-stage cardiac or pulmonary failure may be under consideration for heart or lung transplantation along with bridging therapies such as ventricular assist device implantation or venovenous extracorporeal membrane oxygenation, respectively. Early identification of frail patients in an attempt to modify the risk of postoperative morbidity and mortality has become an important area of study over the last decade. Many quantification tools and risk prediction models for frailty have been developed but have not been evaluated extensively or standardized in the cardiothoracic transplant candidate population. Heightened awareness of frailty, coupled with a better understanding of distinct cellular mechanisms and biomarkers apart from end-stage organ disease, may play an important role in potentially reversing frailty related to organ failure. Furthermore, the clinical management of these critically ill patients may be enhanced by waitlist and postoperative physical rehabilitation and nutritional optimization.

Keywords: COPD; ECMO; IABP; ICU; IGF-1; LVAD; biomarker; cachexia; cardiothoracic surgery; chronic lung disease; critical care; frailty; growth hormone; heart failure; heart transplantation; lung transplantation; metabolism; nutrition; rehabilitation; sarcopenia.

Figure 1.

The Frailty Concept. In a simple model displaying the clinical trajectory of a frail patient compared with a nonfrail phenotype, a clinical insult such as an illness may worsen each patient’s clinical condition (dotted line with arrowheads). The frail patient, however, requires less clinical insult to rapidly decompensate below the level of intrinsic physiologic reserve and become critically ill (purple line). The nonfrail patient has more time to respond to treatment and has a stronger chance of recovery (green line) when compared with the frailty phenotype.

Figure 2.

Disease-Related Frailty vs. Age-Related Frailty. Using the Frailty phenotype illustrated in Figure 1, the patient with disease-related frailty may clinically improve (blue line) after organ transplantation or implementation of bridging therapy (dotted line with circles), such as LVAD implantation or ECMO deployment. Destination therapy LVAD implantation may also display a similar improvement in clinical trajectory. Conversely, a frail patient with age-related disease may have a lower chance for improvement with organ transplantation or bridging therapy and therefore rapid decompensation may result in a higher incidence of reduce survival (red line).