Introduction
Heart failure has become increasingly prevalent with more than 6.5
million Americans currently impacted (1). Individuals of lower
socioeconomic classes are significantly more likely to develop heart
failure compared with their wealthier counterparts (2). Differences in
the allocation of medical resources, access to quality medical care,
ability for self-care, level of education, and generalized support are
among the multifactorial reasons that contribute to this disparity (2,
3). Heart transplantation remains the gold standard for patients
experiencing end stage heart disease. However, due to the paucity of
donor hearts and the multiple contraindications based on strict
transplantation recipient criteria, this option is limited to a small
select group of individuals (4). When controlling for risk factors for
post-transplant mortality, individuals of lower socioeconomic class have
also been shown to have worse outcomes and decreased post-transplant
survival (3-6). Socioeconomic deprivation may modify several
cardiovascular risk factors, making these individuals even less likely
to be considered for transplantation. The utilization of alternative
therapies is currently thriving. LVADs double the one-year survival rate
of patients with end-stage heart failure as compared with drug treatment
alone and provide an effective alternative to individuals who are unable
to receive a transplant (7, 8). LVADs have also advanced to not only
serve as a heart transplantation bridge but also as a destination
therapy. These serial improvements have led to the growing use of LVADs
in a large percentage of the heart failure population. For individuals
of lower socioeconomic classes, numerous studies have shown that these
patients more often had an upfront strategy with LVAD implantation
compared with remaining on pharmacologic therapy and perpetual waiting
on the transplant list (3). The Registry Evaluation of Vital Information
for VADs in Ambulatory Life (REVIVAL) study expanded on this by
demonstrating that there was a greater preference for individuals with
an annual income <$40,000 to receive an LVAD compared with
higher income individuals who were significantly more reluctant to
accept an LVAD (9). As the technology driving LVADs continues to improve
and as more studies demonstrate the benefits of these devices as
destination therapy, together with an increased willingness of a
population subset to receive these devices, it is important to look at
the rate of utilization of these devices across different socioeconomic
classes. Our study aims to analyze the current trends and variances in
LVAD utilization and to further delve into the reasons for, and
implications of, these socioeconomic disparities.