Advanced HF in Finland: Costs, Survival Diverge for Elective vs Urgent LVAD

Patients in Finland with advanced heart failure (HF) derive similar survival—at a similar cost—no matter whether they are treated with an elective left ventricular assist device (LVAD) or undergo heart transplantation. Urgent LVAD implantation, on the other hand, is more expensive and appears to worsen outcomes.

The observational findings, from Helsinki University Hospital, Finland, were published online recently in ESC Heart Failure.

As in other countries, “heart failure is a leading cause of hospitalizations in Finland, with severe cases linked to poor prognosis and high healthcare costs,” Riina Kandolin, MD (Helsinki University Hospital), and colleagues write. LVAD implantation and heart transplant each play important roles in addressing advanced HF, they say, but cost-effectiveness studies comparing the two options, as well as medical management, “remain limited worldwide and much of the economic evidence is based on older LVAD models.”

Finland has a publicly funded healthcare system for its more than 5 million inhabitants and no significant private or insurance-based care. “Particularly, surgical heart failure treatment is fully reimbursed, and medical therapy is reimbursed after relatively low annual cutoff,” the researchers note. “Advanced heart failure care is centralized in five tertiary university hospitals, and all organ transplantations and LVAD implantations are performed in Helsinki University Hospital.”

Kandolin, in an email, observed that there are “fairly little real-life data on LVAD costs,” particularly when it comes to heart transplant versus the unique scenarios of elective or urgent LVAD. Their findings, she said, “can likely be generalized to other countries with similar healthcare systems and most European countries.”

Real-world Data

Kandolin and colleagues analyzed data from electronic medical records for 78 advanced HF patients who were treated at their center between 2022 and 2025. Mean age was approximately 53 years, 77% were male, and all were white. The investigators categorized patients into three groups based on whether they:

• Underwent heart transplantation as the first procedure, stratified into those with (n = 11) and without (n = 25) a prior LVAD
• Received an elective LVAD (n = 30), with or without subsequent transplant
• Had an urgent LVAD (n = 12) after being on extracorporeal membrane oxygenation (ECMO) support for cardiogenic shock not responsive to inotropes, vasopressors, intra-aortic balloon pump, or coronary intervention

Each of the three groups had similar age, sex, and body mass index. The transplant patients tended to have lower NYHA class, “reflecting greater clinical stability—partly due to [some having] prior LVAD implantation before the study period,” the researchers point out. Patients receiving urgent LVAD, on the other hand, tended to have higher NYHA class and “demonstrated worse pathology markers, consistent with advanced HF and the need for urgent intervention.”

By 24 months, survival was 84.0% for patients who underwent transplantation without a prior LVAD. Most of those deaths occurred within the first 3 months. For the patients given a heart transplant on the backdrop of a prior LVAD, survival was 100%.

Within the LVAD-only group, those whose implant was elective had a 24-month survival rate of 93.4%, with two early deaths. Those whose implant was urgent had much worse survival, at 62.5%.

Confidence intervals for survival overlapped between groups, the researchers acknowledge. Still, they say, “the observed difference may be clinically meaningful and suggest that patient stability at the time of implantation could influence prognosis.”

The divide between elective versus urgent LVAD may reflect in-hospital differences, they propose. Those whose device was elective had shorter ICU stays (median 5 vs 20.5 days), ventilator times (median 2 vs 13 days), and hospital stays (median 21 vs 55.5 days; P < 0.001 for all). Compared with those with urgent placement, the elective group was less likely to need dialysis (6.7% vs 50%; P < 0.01) and a right ventricular assist device (3.3% vs 30%; P < 0.05).

Healthcare expenses clustered within the first 3 months after transplant or LVAD. At this time, median costs per patient were €177,380 for transplant after prior LVAD, €207,826 for transplant without prior LVAD, €187,558 for the elective LVAD group, and €293,355 for the urgent LVAD group.

Costs were significantly higher for urgent LVAD placement than for transplant with prior LVAD or elective LVAD. When pooling both transplant groups together, the cost was lower than that seen with urgent LVAD. However, the differences were no longer significant at either 12 or 24 months, perhaps “due to wider cost variation or diminishing sample size,” Kandolin et al note.

“These insights provide a foundation for optimizing patient selection and care pathways in this high-risk population” they conclude.

Kandolin told TCTMD that, when selecting patients for elective LVAD, the decision rests on signs of progressive HF, such as hospitalization, intolerance of medical therapy, and worsening kidney function. “One should pay attention to the right ventricle and act before it deteriorates significantly,” she advised, adding that patients already on ECMO should be carefully assessed “to evaluate whether they would benefit from LVAD.”

As for future research, she hopes to see longer-term follow-up to gauge costs and complications as well as studies from other countries.

Joseph G. Rogers, MD (The Texas Heart Institute, Houston), commenting on the Finnish study for TCTMD, urged caution in interpreting its data. “The sample is very small,” he said via email, noting the “substantial risk of confounding based on severity of baseline illness.” Like Kandolin, Rogers specified that applicability of these data outside of Finland hinges on whether other regions have similar practice patterns and payment systems.