Recommendations for the use of mechanical circulatory support: device strategies and patient selection: a scientific statement from the American Heart Association

Outcomes of left ventricular unloading with a transseptal cannula during extracorporeal membrane oxygenation in adults

We evaluated the benefit of left ventricular (LV) unloading using a percutaneous transseptal left atrial (LA) drain catheter via femoral vein incorporated into the ECMO venous circuit. This single-center retrospective observational study analyzed clinical outcomes of the LA venting group (N = 62) who underwent percutaneous transseptal LA drain placement comparing with the conventionally treated control group (N = 62) with an arterial pulse pressure below 10 mm Hg for at least 24 hours from December 2012 to August 2018. The ECMO weaning rate (61.3% vs. 38.7%, P = .012) and cardiac transplantation rate (29.0% vs. 11.3%, P = .014) were higher in the LA venting group than in the control group. Inhospital mortality was not significantly different (56.5% vs. 69.4%, P = .191). Pulmonary congestion mostly improved after LA decompression (61.3%, P = .003). A serum lactate level at 24 hours after LA venting of more than 2.2 mmol/L was associated with poor outcomes. LA venting via transseptal cannula reduced pulmonary venous congestion and achieved higher rates of successful ECMO weaning and cardiac transplantation. Placement of a transseptal venous drain cannula should be considered in patients with uncontrolled pulmonary edema secondary to severe LV loading undergoing VA-ECMO.

Association Between "Unacceptable Condition" Expressed in Palliative Care Consultation Before Left Ventricular Assist Device Implantation and Care Received at the End of Life

CONTEXT

Palliative care consultation before left ventricular assist device (LVAD) surgery (PreVAD) has been recommended, but its impact on goal-concordant care is unknown.

OBJECTIVES

To describe the association between patients' unique unacceptable condition articulated during PreVAD with the actual care provided at the end of life.

METHODS

Among 308 patients who had PreVAD between 2014 and 2019, 72 patients died before December 31, 2019. Based on the answers to the question, "Is there any condition you would find unacceptable?" patients were divided into ARTICULATE (those who could articulate their unacceptable condition clearly, n = 58) and non-ARTICULATE (those who could not, n = 14). Circumstances at death and end-of-life care were compared between groups.

RESULTS

Mean age at death was 63.2 years (SD ±13.1), 56 patients (77.8%) were males, and median duration of LVAD was 167.5 days (interquartile range 682). ARTICULATE patients died less frequently in the intensive care unit than non-ARTICULATE patients (33 patients, 57.9% vs. 13 patients, 92.9%; P = 0.014) and had ethics consultation less frequently (four patients, 6.9% vs. five patients, 35.7%; P = 0.011). Frequency of LVAD withdrawal was similar in both groups. Among ARTICULATE cohort, the unacceptable condition articulated in PreVAD did not seem to influence decisions at the end of life.

CONCLUSION

Patients who articulated their unacceptable condition clearly before LVAD surgery had less frequent ethics consultations and received less intensive care at the end of life, but it did not seem to affect the decision of LVAD withdrawal. It may be more important to engage in discussions around their unacceptable conditions, rather than the specific condition articulated. The question of an unacceptable condition should be part of any routine palliative care consultation before LVAD surgery.

Discharge survival of patients undergoing ECMO therapy after ECPR in a third level hospital

GOAL

The goal of this study was to assess the survival to hospital discharge in patients after the implementation of venoarterial-extracorporeal membrane oxygenation (VA-ECMO) during cardiopulmonary arrest (simultaneously or during the first six hours after the event) in a Spanish tertiary hospital.

METHOD

This is a descriptive and retrospective study conducted with patients subjected to VA-ECMO therapy during or after cardiopulmonary resuscitation (ECPR) in the last 10 years. The variables were extracted from the electronic medical record of each patient.

RESULTS

175 ECMO therapies were implemented, 84% (147) were VA-ECMO, and the indication for 17% (25) was ECPR. In 40% (10), ECMO therapy was initiated simultaneously during CPR, and the rest (15) during the first six hours after the event. Survival rates reached 44%.

CONCLUSIONS

The use of CPR in well-selected patients can improve their survival.

Hybrid Catheter-Based and Surgical Techniques for Ablation of Ventricular Arrhythmias

Catheter ablation is a rapidly expanding and evolving field. The advent of interventional techniques and advances in technology have allowed catheter ablation to supplant antiarrhythmic surgery for ventricular arrhythmia treatment. However, issues related to access and energy delivery limit the use of catheter ablation in some cases. Hybrid catheter-based and surgical techniques represent a novel approach to overcome these limitations. The hybrid technique combines the strengths and minimises the limitations of either catheter or surgical ablation alone. There is a growing body of evidence in the literature supporting the safety and efficacy of the hybrid surgical technique. This review aims to provide an overview of hybrid surgical-catheter ablation for ventricular arrhythmia.

Gastrointestinal Bleeding as a Complication in Continuous Flow Ventricular Assist Devices: A Systematic Review With Meta-Analysis

Background

The use of ventricular assist devices (VADs) has become predominant in this era of medicine. It is commonly used as a bridge to transplant, recovery and as a destination therapy for patients with severe heart failure, who are not responsive to maximum optimal management or ineligible for transplant. However, several complications are known to occur with the use of these devices. In this research, we will compare gastrointestinal bleeding in patients who used centrifugal flow versus axial flow VADs. We hope that the result of this meta-analysis and the review presented provide adequate information to future researchers, physicians and other healthcare professionals who are interested in this topic.

Methods

Published articles evaluated for inclusion were obtained from MEDLINE (PubMed), Cochrane, EBSCO, clinicaltrials.gov, and international clinical trials registry. This research was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Procured articles were reviewed by two independent reviewers. Only randomized control trials and observational studies were used. Quality assessment was done with Cochrane Collaboration’s tool (RoB.2 with visualization through robviz) and Newcastle-Ottawa Scale (NOS). Data analysis was carried out with the use of R data analysis tool (version 4.0.0; release date: April 24th, 2020).

Results

At the end of this meta-analysis, the occurrence of gastrointestinal bleeding was not significantly different between both groups; with odds ratio (OR): 0.81; 95% confidence interval (CI): 0.65 - 1.00; P value = 0.05. Between-study variance (Tau-squared) was zero (0), standard error (SE) = 0.06. The degree of heterogeneity measured with I-squared statistic was 0% (minimal). Egger’s regression test was not statistically significant, P = 0.93. Symmetry of distribution was observed on the funnel plot. Trim and fill analysis showed no missing studies on the left; SE = 1.68.

Conclusions

The result obtained from this research indicates that the occurrence of gastrointestinal bleeding is not significantly different in both groups of patients, irrespective of the type of continuous flow VAD used. Although, the study sample used in this meta-analysis was limited.

Temporary circulatory support for cardiogenic shock

Cardiogenic shock can occur due to acute ischaemic or non-ischaemic cardiac events, or from progression of long-standing underlying heart disease. When addressing the cause of underlying disease, the management of cardiogenic shock consists of vasopressors and inotropes; however, these agents can increase myocardial oxygen consumption, impair tissue perfusion, and are frequently ineffective. An alternative approach is to temporarily augment cardiac output using mechanical devices. The use of these devices-known as temporary circulatory support systems-has increased substantially in recent years, despite being expensive, resource intensive, associated with major complications, and lacking high-quality evidence to support their use. This Review summarises the physiological basis underlying the use of temporary circulatory support for cardiogenic shock, reviews the evidence informing indications and contraindications, addresses ethical considerations, and highlights the need for further research.

Heart failure units: State of the art in disease management

The prevalence of heart failure has increased over the past decades and is a major social and economic burden on healthcare services. Patient quality of life is severely impaired and heart failure is one of the main causes of death in Portugal. The functional organization of multidisciplinary teams engaged in the treatment of these patients is essential to improve health care provision and outcomes, specifically reducing mortality, hospital admissions, and improving quality of life. We describe current approaches to heart failure management and discuss the organization of heart failure units and cooperation among these units and also with other healthcare professionals.

Frequency of Management of Cardiogenic Shock With Mechanical Circulatory Support Devices According to Race

Mechanical circulatory support (MCS) has influenced the management of cardiogenic shock (CS), but the association between race and MCS utilization is unknown. We sought to evaluate the effect of race on MCS utilization in CS and whether there are racial differences in in-hospital outcomes. Our study was a population-based retrospective cohort study that enrolled patients with CS, defined by International classification of disease, ninth Revision, clinical modification (ICD-9-CM) codes, between 2013 and 2015 from the National Inpatient Sample. Race was adjudicated by National Inpatient Sample and included White, Black, Hispanic, Asian, and Native American. The primary outcomes were the utilization of MCS devices in CS with and without acute myocardial infarction (AMI), and in-hospital mortality by race. The statistical adjustment was performed for clinical co-morbidities as well as in-hospital events using multivariate logistic regressions. Among 332,885 patients with CS, there were 71% white and 14% black patients, and AMI was present in 42% and MCS was utilized in 23% of patients. There was less utilization of MCS only in Black patients with CS, and with AMI after adjustment (odds ratio [OR] 0.84, 95% confidence interval [CI][0.79 to 0.89] and OR 0.85, 95% CI 0.78 to 0.92, respectively). In addition, only Black patients had greater in-hospital mortality in AMI after adjustment (OR 1.16, 95% CI [1.06 to 1.27]) whereas there was no statistically significant increase in in-hospital mortality in any other race. In conclusion, these results suggest that there is less utilization of MCS devices and, in parallel, increased odds of in-hospital mortality in Black patients in comparison to other races. Further steps may be needed to address possible implicit bias in acute clinical scenarios as new devices emerge, which carries new opportunities to improve clinical outcomes but there is a lack of clear guidelines.

Mechanical assist devices for acute cardiogenic shock

BACKGROUND

Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion due to a primary cardiac disorder. For people with refractory CS despite maximal vasopressors, inotropic support and intra-aortic balloon pump, mortality approaches 100%. Mechanical assist devices provide mechanical circulatory support (MCS) which has the ability to maintain vital organ perfusion, to unload the failing ventricle thus reduce intracardiac filling pressures which reduces pulmonary congestion, myocardial wall stress and myocardial oxygen consumption. This has been hypothesised to allow time for myocardial recovery (bridge to recovery) or allow time to come to a decision as to whether the person is a candidate for a longer-term ventricular assist device (VAD) either as a bridge to heart transplantation or as a destination therapy with a long-term VAD.

OBJECTIVES

To assess whether mechanical assist devices improve survival in people with acute cardiogenic shock.

SEARCH METHODS

We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and Web of Science Core Collection in November 2019. In addition, we searched three trials registers in August 2019. We scanned reference lists and contacted experts in the field to obtain further information. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials on people with acute CS comparing mechanical assist devices with best current intensive care management, including intra-aortic balloon pump and inotropic support.

DATA COLLECTION AND ANALYSIS

We performed data collection and analysis according to the published protocol. Primary outcomes were survival to discharge, 30 days, 1 year and secondary outcomes included, quality of life, major adverse cardiovascular events (30 days/end of follow-up), dialysis-dependent (30 days/end of follow-up), length of hospital stay and length of intensive care unit stay and major adverse events. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta-analyses for the prespecified outcomes Summary statistics for the primary endpoints were risk ratios (RR), hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs).

MAIN RESULTS

The search identified five studies from 4534 original citations reviewed. Two studies included acute CS of all causes randomised to treatment using TandemHeart percutaneous VAD and three studies included people with CS secondary to acute myocardial infarction who were randomised to Impella CP or best medical management. Meta-analysis was performed only to assess the 30-day survival as there were insufficient data to perform any further meta-analyses. The results from the five studies with 162 participants showed mechanical assist devices may have little or no effect on 30-day survival (RR of 1.01 95% CI 0.76 to 1.35) but the evidence is very uncertain. Complications such as sepsis, thromboembolic phenomena, bleeding and major adverse cardiovascular events were not infrequent in both the MAD and control group across the studies, but these could not be pooled due to inconsistencies in adverse event definitions and reporting. We identified four randomised control trials assessing mechanical assist devices in acute CS that are currently ongoing.

AUTHORS' CONCLUSIONS

There is no evidence from this review of a benefit from MCS in improving survival for people with acute CS. Further use of the technology, risk stratification and optimising the use protocols have been highlighted as potential reasons for lack of benefit and are being addressed in the current ongoing clinical trials.

Safe Ambulation of Critically Ill Cardiac Patients With Femoral Balloon Pumps: A Case Cohort Study

We sought to demonstrate the safety of ambulation of patients with intra-aortic balloon pumps (IABPs) inserted via the femoral approach in the setting of 1 cardiovascular surgical intensive care unit and 1 cardiac care unit. We studied 70 patients who had received femoral IABPs at our institution between December 2015 and June 2019 and who met standardized criteria for ambulation. These patients underwent initial standing trials with a specialty standing bed/tilt table and progressed to standing exercises and, ultimately, to ambulation (defined as covering a distance of at least 10 feet) with the physical therapist. A total of 323 sessions of ambulation were successfully performed in 70 patients with IABPs inserted via the femoral approach, for an average of 4.61 sessions per patient. The average ambulation session time was 45 minutes (3-62 minutes, covering a median distance of 420 ft [805 IQR]). Complications were defined as major or minor and were monitored for during and after ambulation. Major complications included limb ischemia, arterial dissection, aortic aneurysm, balloon rupture, significant hemodynamic compromise, and death. Minor complications included balloon migration, infection, paresthesia, changes in balloon augmentation, and hematoma at insertion site. No major complications were associated with ambulation, and only 11 minor complications were observed. The total complication rate was 3.40% for all ambulation sessions. Ambulation of selected patients with femoral IABPs appears to be a safe activity when using the enclosed protocol and selection process. Future studies are required to show that such activities decrease muscle deconditioning in these patients and enhance recovery.

Mechanical Circulatory Support in Transcatheter Aortic Valve Implantation in the United States (from the National Inpatient Sample)

Acute circulatory collapse may rarely occur during transcatheter aortic valve implantation (TAVI). In such cases, immediate mechanical circulatory support (MCS) as a bridge to remedial interventions may be required. To define the rate of MCS utilization in TAVI patients and identify the predictors of MCS utilization in a cohort of TAVI patients. TAVI patients between January 2012 and September 2015 were identified in the National Inpatient Sample (NIS) by using the International Classification of Diseases, 9th Revision. Trend weights were used to generate the national estimates of MCS rate in TAVI. Multivariate regression analysis was done to identify predictors of MCS use. A total 60,985 patients underwent TAVI with 1,695 patients receiving MCS (2.8%) during index hospitalization. The most common type of MCS was intra-aortic balloon pump in 52%, followed by extra corporeal membrane oxygenator in 34%, then percutaneous ventricular assist device in 7.4%. Rate of MCS use declined over the study period from 3% in 2012 (Q1) to 1.8% in 2015 (Q3). The use of MCS during TAVI was associated with 10-fold increase in-hospital mortality (27.1% vs 2.8%, p <0.001). Predictors of MCS were congestive heart failure (OR = 2.58, p <0.001), transapical access (OR = 1.92, p <0.001), respiratory complication (OR = 5.19, p <0.001), acute myocardial infarction (OR = 4.21, p <0.001), cardiac arrest (OR = 10.65, p <0.001), and cardiogenic shock (OR = 19.09, p <0.001). In conclusion, the rate of MCS during TAVI hospitalization in the United States declined between 2012 and 2015. MCS during TAVI was associated with a 10-fold increase in in-hospital mortality.

Considerations for Referral: What Happens to Patients After Being Turned Down for Left Ventricular Assist Device Therapy

BACKGROUND

Left ventricular assist device (LVAD) therapy has revolutionized the treatment options for patients with advanced heart failure. Patient selection is essential for obtaining successful results. However, few data exist concerning the outcomes of patients evaluated for LVAD therapy but subsequently rejected or deferred.

METHODS AND RESULTS

This is a retrospective review of all patients referred for LVAD therapy at our institution between January 2009 and December 2016. Baseline demographics and Interagency Registry for Mechanically Assisted Circulatory Support profiles were collected, and reasons for rejection or deferral for LVAD placement were investigated. A total of 669 patients were referred for LVAD therapy, and 228 patients (34%) were turned down. The yearly acceptance rate ranged between 57% and 75%. The average age of the turned-down cohort was 60.8 ± 12.5 years; 83% were men. Reasons for rejection included: patient being too sick (34%); psychosocial concerns (25%); patient declined (16%); decision was deferred for medical optimization (15%); or patient being too well (10%). The percentage of patients who were rejected due to psychosocial concerns has increased over time (P = 0.02), whereas the rate of deferral for medical optimization has remained stable (P = 0.10). One-year survival after initial LVAD consultation was 42% in those who were too sick, 64% in those with psychosocial concerns, 68% in patients who declined, 86% in those deferred for medical optimization; and 100% in those too well (P < 0.01).

CONCLUSIONS

One-year survival is reduced among patients who were initially turned down for LVAD therapy, except for those in whom this decision was deferred for medical optimization or because the patient was too well. Psychosocial concerns have become a significant barrier to LVAD therapy.

[Mechanical circulatory support in terminal heart failure]

BACKGROUND

After exhaustion of all conservative measures in the treatment of acute and chronic heart insufficiency, there is the possibility to temporarily or permanently support or replace the pump performance of the heart by mechanical circulatory support (MCS) systems.

OBJECTIVE

Presentation of the most important cardiac support systems for intensive care medicine, their indications and important risk factors.

MATERIAL AND METHODS

Critical review of device manufacturer's specifications, current research and expert opinions.

RESULTS

The spectrum of available MCS procedures include mechanical chest compression devices, catheter-based micropumps and complete artificial hearts. Device selection depends on the severity of heart failure (monoventricular or biventricular pump failure), the expected duration of treatment and the degree of lung function impairment. The decision between minimally invasive and open surgical procedures depends on the options established at the specific healthcare institution and whether the heart function is to be temporarily or permanently replaced. Compliance with the anticoagulation regimens defined by the manufacturer is especially important as they differ vastly between devices and are critical to avoid bleeding or thromboembolic complications.

CONCLUSION

Due to the increasing number of patients on long-term mechanical circulatory support, the chances are that physicians in the initial emergency admission are unfamiliar with these devices but need to operate them in emergency cases. Therefore, knowledge of these procedures and their complications becomes increasingly important.

2019 EACTS Expert Consensus on long-term mechanical circulatory support

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.

Mental health interventions during ventricular assist device therapy: a scoping review

OBJECTIVES

Because of the high prevalence of psychological disorders among ventricular assist device patients, mental health support is consensually recommended. No study as yet has provided an overview of recommended and reported mental health interventions. This article presents the results of a scoping review on these questions.

METHODS

We searched standard databases for relevant search criteria and found 4 consensus guidelines and 13 publications with original research mentioning mental health interventions for ventricular assist device patients. These publications are synthesized and augmented with practical recommendations from our reports and from a single-centre experience of others.

RESULTS

Consensus guidelines recommend mental health interventions in 4 areas: screening and diagnostics, assessment, support and treatment and education. Interventions vary across treatment phases and by device therapy strategy, as do typical sources of mental distress. A flow chart of interventions over the course of treatment summarizes these findings.

CONCLUSIONS

The delivery of consensually recommended mental health support for ventricular assist device patients involves the performance of multiple, complex tasks that vary across treatment phases. Mental health professionals should have specialized skills and should interact frequently with other caregivers in care teams.

Pediatric Ventricular Assist Device

There have been great advances in ventricular assist device (VAD) treatment for pediatric patients with advanced heart failure. VAD support provides more time for the patient in the heart transplant waiting list. Augmented cardiac output improves heart failure symptoms, end-organ function, and general condition, and consequently provides beneficial effects on post-transplant outcomes. Miniaturized continuous flow devices are more widely adopted for pediatric patient with promising results. For infants and small children, still paracorporeal pulsatile device is the only option for long-term support. Younger age, congenital heart disease, biventricular support, patient's status and end-organ dysfunction at the time of implantation are risks for poor outcomes. Patient selection, timing of implantation, and selection of device for each patient are critical for optimal clinical outcomes.

Circulatory support and stem cell therapy in the management of advanced heart failure: a concise review of available evidence

Stem cell therapy utilizing bone marrow mononuclear cells (BMC's) is a potential strategy to treat heart failure patients with improvement in symptom profile and cardiac function. We describe a rationale for concurrent BMC and left ventricular assist device therapy in selected heart failure patients. This combination therapy has demonstrated improved myocardial perfusion and cardiac function in patients with advanced ischemic cardiomyopathy. Moreover, preclinical data support improved cell retention with left ventricular unloading. The beneficial effects of BMC's are likely through a paracrine mechanism initiating a 'cardiac-repair' process. Combination therapy of BMC's and a left ventricular assist device may exhibit a synergistic effect with improved engraftment of BMC's through left ventricular unloading.

Left ventricular assist devices in the treatment of advanced heart failure

The left ventricular assist device (LVAD) is becoming the standard of care in treating patients with advanced heart failure. This article describes available LVADs, their clinical indications, and important caveats when caring for this complex patient population.

Family caregiver-reported outcomes regarding decision-making for left ventricular assist device implantation

BACKGROUND

Family caregivers (FCGs) often participate in the decision for their loved one to receive a left ventricular assist device (LVAD). Little is known about the contribution of FCGs to this complex decision.

OBJECTIVES

To investigate family caregiver-reported outcomes related to decision-making for LVAD implantation and their experiences post-implantation.

METHODS

Descriptive thematic analysis was used to analyze longitudinal data. Thematic saturation was achieved.

RESULTS

Three key themes emerged from the data. The main theme in the pre-implantation period was: Not a decision. The two themes in the post-implantation period were: More satisfaction than regret and Unanticipated situational change.

CONCLUSIONS

Family caregiver-reported outcomes inform clinical practice and future research. FCGs of LVAD recipients did not see viable alternatives to LVAD implantation, were generally satisfied with post-implantation outcomes, and experienced unexpected life changes in the post-implantation period despite feeling prepared preoperatively. Education of both LVAD recipients and their FCGs must be optimized.

Peripartum Cardiomyopathy: Current Options for Treatment and Cardiovascular Support

Peripartum cardiomyopathy is a rare form of acute heart failure but the major cause of all deaths in pregnant patients with heart failure. Improved survival rates in recent years, however, emphasize the importance of early recognition and initiation of heart failure treatment. This article, therefore, attempts to raise awareness among cardiac and obstetric anesthesiologists as well as intensivists of this often fatal diagnosis. This review summarizes theories of the pathophysiology and outcome of peripartum cardiomyopathy. Based on the most recent literature, it further outlines diagnostic criteria and treatment options including medical management, mechanical circulatory support devices, and heart transplantation. Earlier recognition of this rare condition and a new generation of mechanical circulatory devices has contributed to the improved outcome. More frequently, patients in cardiogenic shock who fail medical management are successfully bridged to recovery on extracorporeal circulatory devices or survive with a long-lasting implantable ventricular assist device. The outcome of transplanted patients with peripartum cardiomyopathy, however, is worse compared to other recipients of heart transplants and warrants further investigation in the future.

Implications of Transitional Care Interventions on Hospital Readmissions in Patients With Destination Therapy Left Ventricular Assist Devices

BACKGROUND

The rising number of patients with a left ventricular assist device (LVAD) require care management to successfully transition home after implantation. These patients and their families need to manage their heart failure, and the complexities of an LVAD and the associated lifestyle modifications. Translating knowledge of transitional care interventions in patients with chronic diseases to those with an LVAD may provide valuable insight. To help inform the furthering of care transitions in the LVAD patient population, an integrative review was conducted.

AIM

The aim of this review was to explore the transitions of care interventions of care in patients and its potential for application in the destination therapy LVAD.

METHODS

This integrative review was guided by the Whittemore and Knafl's methodology.

RESULTS

A total of 12 articles from 264 retrieved articles met inclusion criteria and were included in the literature review.

DISCUSSION

This review identified that evidence-based transitional care interventions have been shown to decrease avoidable rehospitalization, the associated costs, and improve quality of life when compared to usual care.

IMPLICATIONS FOR PRACTICE

A common feature of transitional care interventions is the inclusion of nurse leadership. Nurses should be prepared to participate in transitional care interventions to optimally improve outcomes for patients with heart failure and potentially those with an LVAD. Additionally, to make transitional care interventions more effective they should be implemented with moderate intensity or greater.

CONCLUSION

This review provided information supporting the trialing of transitional care interventions in patients with an LVAD and suggests pilot research to optimize interventions for this population.

Preoperative Predictors of Mortality in Short-Term Continuous-Flow Ventricular Assist Devices

Short-term continuous-flow ventricular assist devices (STCF-VADs) are increasingly being utilized to support critically ill patients, despite limited information regarding overall outcomes. All adult patients supported with an STCF-VAD between June 2009 and December 2015 were included in this retrospective single-center study. Associations between preoperative characteristics and unsuccessful bridge (death on device or within 30 days postdecannulation) were assessed using logistic regression. A total of 61 patients (77% male) were identified with a median age at implant of 54.6 years. Left VADs were implanted in 51%, right VADs in 21%, and both VADs in 28%, and patients were supported for a median of 11 days. Overall, 23% were weaned to recovery, 13% underwent heart transplantation, 16% converted to long-term VADs, and 48% had an unsuccessful bridge. In multivariable analysis, only renal insufficiency or dialysis (odds ratio = 7.53; p = 0.002) remained a significant independent predictor of an unsuccessful bridge. Short-term continuous-flow VADs can successfully bridge adult patients with mortality around 50%. Preimplant renal insufficiency or dialysis is correlated with an unsuccessful bridge in our patient population, likely reflecting the severity of illness preimplant. Further studies are required to determine whether this factor remains significant in a larger patient population.

Management of advanced heart failure: a review

INTRODUCTION

Heart failure (HF) has become a global pandemic. Despite recent developments in both medical and device treatments, HF incidences continues to increase. The current definition of HF restricts itself to stages at which clinical symptoms are apparent. In advanced heart failure (AdHF), it is universally accepted that all patients are refractory to traditional therapies. As the number of HF patients increase, so does the need for additional treatments, with an increased proportion of patients requiring advanced therapies. Areas covered: This review discusses extensive evidence for the effect of medical treatment on HF, although the data on the effect on AdHF is scare. Authors review the relevant literature for treating AdHF patients. Furthermore, mechanical circulatory devices (MCD) have emerged as an alternative to heart transplantation and have been shown to enhance quality of life and reduce mortality therefore authors also review the current literature on the different MCD and technologies. Expert commentary: More patients will need advanced therapies, as the access to heart transplantation is limited by the number of available donors. AdHF patients should be identified timely since the window of opportunities for advanced therapy is narrow as their morbidity is progressive and survival is often short.

Caregivers of Patients Considering a Destination Therapy Left Ventricular Assist Device and a Shared Decision-Making Intervention: The DECIDE-LVAD Trial

OBJECTIVES

This study aims to characterize caregivers of patients considering destination therapy left ventricular assist device (DT-LVAD) and evaluate the effectiveness of a shared decision-making (SDM) intervention.

BACKGROUND

Caregivers play an integral role in the care of patients with chronic illness. At the extreme, pursuing a DT-LVAD is a major preference-sensitive decision that requires high-level caregiver engagement. Yet, little is known about caregivers of patients considering DT-LVAD, and there is a paucity of research on the involvement of caregivers in medical decision-making.

METHODS

A 6-center, stepped-wedge trial was conducted. After varying time in usual care (control), sites were transitioned to an SDM intervention consisting of staff education and pamphlet and video decision aids (DAs). The primary outcome was decision quality, measured by knowledge and values-choice concordance.

RESULTS

From 2015 to 2017, 182 caregivers of patients considering DT-LVAD were enrolled (control group, n = 111; intervention group, n = 71). The median age was 61 years, 86.5% were female, and 75.8% were spouses. Caregiver knowledge (0% to 100%) improved from baseline to post-education in both groups: in the control group it improved from 64.2% to 73.3%; in the intervention group it improved from 62.6% to 76.4% (adjusted difference of difference: 4.8%; p = 0.08). At 1 month, correlation between stated values and caregiver-reported treatment choice was stronger in the intervention group (difference in Kendall's tau: 0.36, 95% confidence interval: 0.04 to 0.71; p = 0.03). Caregivers reported decisional conflict (0 to 100) at baseline (control group: 19.0 ± 2.1; intervention group: 21.4 ± 2.6), which decreased post-education more in the control group (control group: 9.0 ± 1.9, intervention group: 18.8 ± 2.4; p = 0.009). Caregivers in the control group were more likely to "definitely recommend" the educational materials than those in the intervention group (93.5% vs. 74.5%, respectively; p = 0.004).

CONCLUSIONS

An SDM intervention improved concordance between caregiver values and treatment choice for their loved ones but did not significantly impact knowledge. Caregivers found the DAs less acceptable than more biased educational materials and exposure to DAs led to higher conflict initially. These findings highlight the complexity of SDM involving caregivers of patients with chronic illness. (PCORI-1310-06998 Trial of a Decision Support Intervention for Patients and Caregivers Offered Destination Therapy Heart Assist Device [DECIDE-LVAD]; NCT02344576).

Exercise-based cardiac rehabilitation for people with implantable ventricular assist devices

BACKGROUND

Heart failure is the end stage of heart disease, and the prevalence and incidence of the condition is rapidly increasing. Although heart transplantation is one type of surgical treatment for people with end-stage heart failure, donor availability is limited. Implantable ventricular assist devices (VADs) therefore offer an alternative treatment to heart transplantation. Although two studies reported the beneficial effects of exercise-based cardiac rehabilitation (CR) on functional capacity and quality of life (QOL) by performing systematic reviews and meta-analyses, both systematic reviews included studies with limited design (e.g. non-randomised, retrospective studies) or participants with implantable or extracorporeal VADs.

OBJECTIVES

To determine the benefits and harms of exercise-based CR for people with implantable VADs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase, PsycINFO, Conference Proceedings Citation Index-Science (CPCI-S) on Web of Science, CINAHL, and LILACS on 3 October 2017 with no limitations on date, language, or publication status. We also searched two clinical trials registers on 10 August 2017 and checked the reference lists of primary studies and review articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) regardless of cluster or individual randomisation, and full-text studies, those published as abstract only, and unpublished data were eligible. However, only individually RCTs and full-text publications were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted outcome data from the included studies. We double-checked that data were entered correctly by comparing the data presented in the systematic review with the study reports. We had no dichotomous data to analyse and used mean difference or standardised mean difference with 95% confidence intervals (CIs) for continuous data. Furthermore, we assessed the quality of evidence as it relates to those studies that contribute data to the meta-analyses for the prespecified outcomes, using GRADEpro software.

MAIN RESULTS

We included two studies with a total of 40 participants in the review. Exercise-based CR consisted of aerobic or resistance training or both three times per week for six to eight weeks. Exercise intensity was 50% of oxygen consumption (VO2) reserve, or ranged from 60% to 80% of heart rate reserve. Two serious adverse events were observed in one trial, in which participants did not complete the study due to infections. Furthermore, a total of four participants in each group required visits to the emergency department, although these participants did complete the study. Summary scores from the 36-item Short Form Health Survey (SF-36) and the Kansas City Cardiomyopathy Questionnaire (KCCQ) were measured as quality of life. One trial reported that the KCCQ summary score improved by 14.4 points in the exercise group compared with 0.5 points in the usual care group. The other trial reported that the SF-36 total score improved by 29.2 points in the exercise group compared with 16.3 points in the usual care group. A large difference in quality of life was observed between groups at the end of follow-up (standardised mean difference 0.88, 95% CI -0.12 to 1.88; 37 participants; 2 studies; very low-quality of evidence). However, there was no evidence for the effectiveness of exercise-based CR due to the young age of the participants, high risk of performance bias, very small sample size, and wide confidence intervals, which resulted in very low-quality evidence. Furthermore, we were not able to determine the effect of exercise-based CR on mortality, rehospitalisation, heart transplantation, and cost, as these outcomes were not reported.

AUTHORS' CONCLUSIONS

The evidence is currently inadequate to assess the safety and efficacy of exercise-based CR for people with implantable VADs compared with usual care. The amount of RCT evidence was very limited and of very low quality. In addition, the training duration was very short term, that is from six to eight weeks. Further high-quality and well-reported RCTs of exercise-based CR for people with implantable VADs are needed. Such trials need to collect data on events (mortality and rehospitalisation), patient-related outcomes (including quality of life), and cost-effectiveness.

Antithrombotic therapy in ventricular assist device (VAD) management: From ancient beliefs to updated evidence. A narrative review

Platelets play a key role in the pathogenesis of ventricular assist device (VAD) thrombosis; therefore, antiplatelet drugs are essential, both in the acute phase and in the long-term follow-up in VAD management. Aspirin is the most used agent and still remains the first-choice drug for lifelong administration after VAD implantation. Anticoagulant drugs are usually recommended, but with a wide range of efficacy targets. Dual antiplatelet therapy, targeting more than one pathway of platelet activation, has been used for patients developing a thrombotic event, despite an increased risk of bleeding complications. Although different strategies have been attempted, bleeding and thrombotic events remain frequent and there are no uniform strategies adopted for pharmacological management in the short and mid- or long-term follow up. The aim of this article is to provide an overview of the evidence from randomized clinical trials and observational studies with a focus on the pathophysiologic mechanisms underlying bleeding and thrombosis in VAD patients and the best antithrombotic regimens available.

Implantable Ventricular Assist Device Use and Outcomes in People With End-Stage Renal Disease

Background

People with end‐stage renal disease (ESRD) are at risk for advanced heart failure, but little is known about use and outcomes of durable mechanical circulatory support in this setting. We examined use and outcomes of implantable ventricular assist devices (VADs) in a national ESRD cohort.

Methods and Results

We performed a retrospective cohort study of Medicare beneficiaries with ESRD who underwent implantable VAD placement from 2006 to 2014. We examined in‐hospital and 1‐year mortality, all‐cause and cause‐specific hospitalizations, and heart/kidney transplantation outcomes. We investigated as predictors demographic factors, time‐period of VAD implantation, primary or post‐cardiotomy implantation, and duration of ESRD before VAD implantation. We identified 96 people with ESRD who underwent implantable VAD placement. At time of VAD implantation, 74 (77.1%) were receiving hemodialysis, 10 (10.4%) were receiving peritoneal dialysis and 12 (12.5%) had renal transplant. Time from incident ESRD to VAD implantation was median 4.0 (interquartile range 1.1, 8.2) years. Mortality during the implantation hospitalization was 40.6%. Within 1 year of implantation 61.5% of people had died. On multivariable analysis, males had half the mortality risk of females. Lower mortality risk was also seen with VAD implantation in a primary setting, and with more recent year of implantation, but these results did not reach statistical significance.

Conclusions

Medicare beneficiaries with ESRD are undergoing durable VAD implantation, often several years after incident ESRD, although in low numbers. Mortality is high among these patients, highlighting the need for investigations to improve treatment selection and management.

Current State of Pediatric Heart Failure

Pediatric heart failure (HF) represents an important cause of morbidity and mortality in childhood. There is an overlapping relationship of HF, congenital heart disease, and cardiomyopathy. The goal of treatment of HF in children is to maintain stability, prevent progression, and provide a reasonable milieu to allow somatic growth and optimal development. Current management and therapy for HF in children are extrapolated from treatment approaches in adults. There are significant barriers in applying adult data to children because of developmental factors, age variation from birth to adolescence, and differences in the genetic expression profile and &beta;-adrenergic signaling. At the same time, there are significant challenges in performing well-designed drug trials in children with HF because of heterogeneity of diagnoses identifying a clinically relevant outcome with a high event rate, and a difficulty in achieving sufficient enrollment. A judicious balance between extrapolation from adult HF guidelines and the development of child-specific data on treatment represent a wise approach to optimize pediatric HF management. This approach is helpful as reflected by the increasing role of ventricular assist devices in the management of advanced HF in children. This review discusses the causes, epidemiology, pathophysiology, clinical manifestations, conventional medical treatment, clinical trials, and the role of device therapy in pediatric HF.

Utility of the Psychosocial Assessment of Candidates for Transplantation in Patients Undergoing Continuous-Flow Left Ventricular Assist Device Implantation

Purpose:

Psychosocial assessment of patients comprises an important element in the selection process of appropriate candidates for left ventricular assist device (LVAD) implantation. We sought to determine the association of the well-validated psychosocial assessment of candidates for transplantation (PACT) scale to clinical outcomes post-LVAD implantation.

Materials and Methods:

The PACT scale was used retrospectively to reconstruct psychosocial profiles of all patients who underwent a continuous-flow LVAD implantation for all indications at our institution between March 2008 and August 2012 (N = 230). Psychosocial elements including social support, psychological health, lifestyle factors, comprehension of the operation, and follow-up were evaluated. The primary outcome was overall survival, and the secondary outcomes were hospital readmission, pump thrombosis, hemolysis, gastrointestinal (GI) bleeding, and LVAD driveline infections.

Results:

The mean age of patients was 55.3 years, with 83% being male; 58% (N = 135) were bridge to transplant and 42% (N = 95) were destination therapy. Up to 1-year post-LVAD implant, there were no statistical differences among the 5 PACT candidate groups in terms of survival ( P = .79), hospital readmissions ( P = .55), suspected or confirmed pump thrombosis ( P = .31), hemolysis ( P = .43), GI bleeding ( P = .71), or driveline infections ( P = .06).

Conclusions:

In this single-center retrospective review, post hoc reconstruction of psychosocial profiles using the PACT scale and independent assessment of postimplant outcomes, including survival and adverse events, did not show any association. However, given the small number of patients in the low score PACT groups as well as limited duration of follow-up, further studies are required to elucidate the association.

Performance Improvement to Decrease Readmission Rates for Patients With a Left Ventricular Assist Device

BACKGROUND

The 30-day readmission rate for patients with a left ventricular assist device implantation at a large, urban, Midwest hospital system (from October 2013 to September 2014) was estimated at 32.1%.

PROBLEM STATEMENT

Readmission rates were a concern at this facility. Review of the readmissions, change in practice, and home expectations of patients and families have identified an opportunity to improve the transitions of care for this left ventricular assist device (LVAD) program. Therefore, the purpose of this project was to evaluate the effectiveness and feasibility of a transitional care model (TCM) for care of patients with left ventricular devices.

METHODS

Ten patients were enrolled in the pilot that was implemented in June 2015. A transitional care nurse trained to support patients with ventricular assist devices was used to facilitate patient flow. The goal was to create an individualized plan for the development or improvement of self-management skills to decrease readmission rates. The transitional care nurse collaborated with the ventricular device team.

OUTCOMES

The 30-day readmission rate during the pilot was 14.3% compared to the previous annual overall rate of 42.6%.

IMPLICATIONS FOR PRACTICE

Based on these results, further research is recommended into interventions consistent with the TCM to advance care coordination and to facilitate care transition in the this fragile patient population.

Patient and Caregiver Determinants of Patient Quality of Life and Caregiver Strain in Left Ventricular Assist Device Therapy

BACKGROUND

Although current guidelines emphasize the importance of social support to the success of left ventricular assist device (LVAD) therapy, few studies examine the influence of the caregiver on patient outcomes or quantify the impact of LVAD caregiving on caregiver outcomes. The purpose of this analysis was to identify patient and caregiver determinants of patient quality of life (QOL) and caregiver strain in response to LVAD therapy.

METHODS AND RESULTS

Data on patients receiving LVAD therapy and their caregivers (n=50 dyads) were prospectively collected pre-implantation and 1, 3, and 6 months post-implantation. Growth curve modeling was used to describe change in patient QOL (Kansas City Cardiomyopathy Questionnaire) and caregiver strain (Multidimensional Caregiver Strain Index). Patient QOL improved most in the first month (β=23.22±3.76, P<0.001), followed by gradual gains over 6 months (β=1.90±0.64, P<0.01). Caregivers experienced worsening of strain in the first month (β=4.30±1.42, P<0.01), followed by gradual resolution to pre-implantation levels by 6 months (β=-0.71±0.23, P<0.01). Worse pre-implantation patient symptoms were associated with greater improvement in patient QOL (β=0.53±0.19, P<0.01) but worsening caregiver strain (β=0.15±0.07, P=0.04). Better relationship quality was associated with greater improvement in patient QOL (β=14.39±5.85, P=0.01) and less pre-implantation caregiver strain (β=-9.31±2.28, P<0.001). Nonspousal caregivers experienced less pre-implantation strain (β=-8.60±3.10, P=0.01), and patients with nonspousal caregivers had less improvement in QOL (β=-3.70±1.62, P=0.02).

CONCLUSIONS

A combination of patient and caregiver characteristics predicts patient and caregiver response to LVAD therapy. Including caregiver factors in future studies may be helpful in developing interventions that improve patient and caregiver outcomes, together.

Defining Ambulatory Advanced Heart Failure: MedaMACS and Beyond

PURPOSE OF REVIEW

Extended survival with LVADs has generated interest in implantation for ambulatory patients with advanced heart failure (HF) prior to dependence on inotropes, though we remain limited in our ability to define and advance indications in this less sick advanced HF population.

RECENT FINDINGS

The MedaMACS and ROADMAP studies have informed prognosis and decision-making for ambulatory patients with advanced HF. Sicker INTERMACS profiles are consistently associated with high risk of death or rescue LVAD. Appropriately selected patients in profile 4 should be considered for LVADs based on their high mortality and poor quality of life. These studies also shed light on discordant perceptions of HF disease severity between patients and their physicians. For ambulatory patients with HF not at imminent risk of death, shared decision-making about LVAD requires measured and individualized consideration of risk and benefit beyond survival. Future studies, including the ongoing REVIVAL study, should provide additional prognostic information in this patient population and should aid patients, caregivers, and physicians as they contemplate complex decisions regarding LVAD therapy.

Heart transplantation versus left ventricular assist devices as destination therapy or bridge to transplantation for 1-year mortality: a systematic review and meta-analysis

Background

The optimal treatment for advanced heart failure (HF) patients with regards to mortality remains unknown. Heart transplantation (HTx) and left ventricular assist devices (LVAD) used either as a bridge to transplant (BTT) or destination therapy (DT) have been compared in a number of studies, without definite conclusions with regards to mortality benefit. We sought to systematically review the pertinent literature and perform a meta-analysis of all the available studies presenting head-to-head comparisons between HTx and LVAD BTT or LVAD DT for late (>6 months) all-cause mortality.

Methods

We performed a systematic search of Medline and Cochrane Central databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We conducted a meta-analysis of late mortality comparing HTx vs. BTT LVAD and HTx vs. DT LVAD using a random effects model.

Results

Eight studies were included in our meta-analysis, reporting data on 7,957 patients in total. Although the available studies are of high quality [8 stars in Newcastle-Ottawa Scale (NOS) on average], there is paucity of mortality data. Specifically, seven studies compared HTx with BTT and five studies compared HTx with DT for 1-year mortality. Our pooled estimates showed that there was no difference in late mortality among these strategies.

Conclusions

Our meta-analysis highlights the small number and the heterogeneity of available studies referring to the optimal invasive management of advanced HF, and shows that there are no differences between HTx and LVAD for these patients with regards to late mortality.