Quality of life and left ventricular assist device support

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.

‘We’re like a gang, we stick together’: experiences of ventricular assist device communities

Background:

Ventricular assist devices (VADs) are a relatively new development in the management of advanced heart failure. In the UK, VAD recipients comprise a unique group of less than 200 patients. This is the first paper to explore the experience of VAD communities, the extent to which communities are developed around the device, and how these influence the experience of living with the VAD.

Methods:

Qualitative interviews were conducted with 20 VAD recipients (implanted as a bridge to transplantation), 11 interviews also included the VAD recipients’ partners. Interpretive phenomenology was employed as the theoretical basis guiding the analysis of the interviews.

Results:

Four key themes emerged from the data: the existence of VAD communities; experiential knowledge and understanding; social comparisons; and the impacts of deaths within the VAD community. Many of the interviewees valued the VAD communities and the relationships they had formed with fellow recipients. The beneficial impacts of the VAD communities included offering recently implanted patients a realistic view of what to expect from life with a VAD; this could aid them in accepting and adapting to the changes imparted by the device. However, negative impacts of the VAD communities were also reported, in particular following deaths within the group, which were a source of distress for many of the interviewees.

Conclusions:

In general, the VAD communities appeared to be a beneficial source of support for the majority of interviewees. Consideration should be given to how these communities could be supported by clinicians.

Measuring quality of life in advanced heart failure

PURPOSE OF REVIEW

Patients with Stage D heart failure can benefit from palliative care consultation to help them manage unpleasant symptoms and improve quality of life. Although guidelines describe how to manage symptoms, very little direction is provided on how to evaluate the effectiveness of those interventions.

RECENT FINDINGS

Numerous studies have used the measurement of symptoms, emotional distress, functional capacity and quality of life to evaluate the effectiveness of interventions in heart failure. There is limited evidence on the use of these instruments in heart failure palliative care. Four studies were identified that evaluate the effectiveness of palliative care consultation for patients with advanced heart failure. All four studies measured symptom severity, emotional distress, and quality of life. The application of appropriate instruments is discussed. Suggestions for scores that should trigger palliative care consultation are identified.

SUMMARY

The routine administration of standardized instruments to measure symptom severity and quality of life may improve the assessment and management of patients with Stage D heart failure. Ongoing discussion and research is needed to determine if these instruments are the best tools to use with heart failure palliative care patients.

Intracorporeal Heat Distribution from Fully Implantable Energy Sources for Mechanical Circulatory Support: A Computational Proof-of-Concept Study

Mechanical circulatory support devices, such as total artificial hearts and left ventricular assist devices, rely on external energy sources for their continuous operation. Clinically approved power supplies rely on percutaneous cables connecting an external energy source to the implanted device with the associated risk of infections. One alternative, investigated in the 70s and 80s, employs a fully implanted nuclear power source. The heat generated by the nuclear decay can be converted into electricity to power circulatory support devices. Due to the low conversion efficiencies, substantial levels of waste heat are generated and must be dissipated to avoid tissue damage, heat stroke, and death. The present work computationally evaluates the ability of the blood flow in the descending aorta to remove the locally generated waste heat for subsequent full-body distribution and dissipation, with the specific aim of investigating methods for containment of local peak temperatures within physiologically acceptable limits. To this aim, coupled fluid-solid heat transfer computational models of the blood flow in the human aorta and different heat exchanger architectures are developed. Particle tracking is used to evaluate temperature histories of cells passing through the heat exchanger region. The use of the blood flow in the descending aorta as a heat sink proves to be a viable approach for the removal of waste heat loads. With the basic heat exchanger design, blood thermal boundary layer temperatures exceed 50°C, possibly damaging blood cells and proteins. Improved designs of the heat exchanger, with the addition of fins and heat guides, allow for drastically lower blood temperatures, possibly leading to a more biocompatible implant. The ability to maintain blood temperatures at biologically compatible levels will ultimately allow for the body-wise distribution, and subsequent dissipation, of heat loads with minimum effects on the human physiology.

Palliative Care Clinicians Caring for Patients Before and After Continuous Flow-Left Ventricular Assist Device

Left ventricular assist devices (LVADs) are an available treatment option for carefully selected patients with advanced heart failure. Initially developed as a bridge to transplantation, LVADs are now also offered to patients ineligible for transplantation as destination therapy (DT). Individuals with a DT-LVAD will live the remainder of their lives with the device in place. Although survival and quality of life improve with LVADs compared with medical therapy, complications persist including bleeding, infection, and stroke. There has been increased emphasis on involving palliative care (PC) specialists in LVAD programs, specifically the DT-LVAD population, from the pre-implantation process through the end of life. Palliative care specialists are well poised to provide education, guidance, and support to patients, families, and clinicians throughout the LVAD journey. This article addresses the complexities of the LVAD population, describes key challenges faced by PC specialists, and discusses opportunities for building collaboration between PC specialists and LVAD teams.

Quality of Life, Depression, and Anxiety in Ventricular Assist Device Therapy: Longitudinal Outcomes for Patients and Family Caregivers

BACKGROUND

Patients who receive ventricular assist device (VAD) therapy typically rely on informal caregivers (family members or friends) to assist them in managing their device.

OBJECTIVE

The purpose of this study is to characterize changes in person-oriented outcomes (quality of life [QOL], depression, and anxiety) for VAD patients and their caregivers together from pre-implantation to 3 months post-implantation.

METHODS

This was a formal interim analysis from an ongoing prospective study of VAD patients and caregivers (n = 41 dyads). Data on person-oriented outcomes (QOL: EuroQol 5 Dimensions Visual Analog Scale; depression: Patient Health Questionnaire-8; anxiety: Brief Symptom Inventory) were collected at 3 time points (just prior to implantation and at 1 and 3 months post-implantation). Trajectories of change for patients and caregivers on each measure were estimated using latent growth modeling with parallel processes.

RESULTS

Patients' QOL improved significantly over time, whereas caregiver QOL worsened. Depression and anxiety also improved significantly among patients but did not change among caregivers. There was substantial variability in change on all outcomes for both patients and their caregivers.

CONCLUSIONS

This is the first quantitative study of VAD patient-caregiver dyads in modern devices that describes change in person-oriented outcomes from pre-implantation to post-implantation. This work supports the need for future studies that account for the inherent relationships between patient and caregiver outcomes and examine variability in patient and caregiver responses to VAD therapy.

Long-term use of left ventricular assist devices: a report on clinical outcomes

BACKGROUND

The literature examining clinical outcomes and readmissions during extended (> 1 yr) left ventricular assist device (LVAD) support is scarce, particularly in the era of continuous-flow LVADs.

METHODS

We completed a retrospective cohort study on consecutive LVAD patients from June 2006 to March 2015, focusing on those who received more than 1 year of total LVAD support time. Demographic characteristics, clinical outcomes and readmissions were analyzed using standard statistical methods. All readmissions were categorized as per the Interagency Registry for Mechanically Assisted Circulatory Support 2015 guidelines.

RESULTS

Of the 103 patients who received LVADs during the study period, 37 received LVAD support for more than 1 year, with 18 receiving support for more than 2 years. Average support time was 786 ± 381 days, with total support time reaching 80 patient-years. During a median follow-up of 2 years, 27 patients died, with 1-year conditional survival of 74%. Median freedom from first readmission was 106 days (range 1-603 d), with an average length of stay of 6 days. Readmissions resulted in an average of 41 ± 76 days in hospital per patient. Reasons for readmission were major infection (24%), major bleeding (19%) and device malfunction/thrombus (13%). There were a total of 112 procedures completed during the readmissions, with 60% of procedures being done in 13% (n = 5) of patients.

CONCLUSION

Continuous-flow LVADs provide excellent long-term survival. The present study describes marked differences in reasons for readmissions between the general LVAD population and those supported for more than 1 year. Prolonged LVAD support resulted in decreased susceptibility to major bleeds and increased susceptibility to infection.

Short-term Results of Heartmate 3 Ventricular Assist Device Implantation for End-Stage Heart Failure

OBJECTIVE

To report our initial experience with Heartmate 3 ventricular assist device (HM3) in cases with end-stage heart failure (ESHF).

METHODS

Charts of 8 ESHF patients who underwent HM3 implantation in our clinic from January to June 2016 (group 1) and 16 patients who underwent HM2 implantation during 2015 (group 2) were reviewed retrospectively. Demographics as well as pre- and early postoperative medical data were noted and statistically analyzed between the 2 groups.

RESULTS

No statistical difference was found in age or sex distribution between groups (P > .05). Mean Interagency Registry for Mechanically Assisted Circulatory Support scores were 2.13 ± 0.99 and 3.38 ± 0.72 in groups 1 and 2, respectively (P = .020). Mean cardiopulmonary bypass time, and chest tube drainage fluid volume and blood product requirement during intensive care unit (ICU) stay were 64.0 ± 13.9 minutes, 1,112.5 ± 516.7 mL, and 318.8 ± 271.2 mL, respectively, in group 1 and 89.0 ± 33.3 minutes, 2,081.3 ± 1,696.0 mL, and 1,118.8 ± 1,010.8 mL in group 2 (P = .027, P = .019, and P = .040, respectively). Need for surgical revision and early mortality were not evident for group 1, although 4 cases (25.0%) required revision surgery, and early mortality was seen in 3 cases (18.8%) in group 2 (P = .121 and P = .190, respectively). Mean durations of ICU stay and total postoperative hospitalization were 5.9 ± 2.0 and 18.3 ± 5.5 days, respectively in group 1 and 6.2 ± 4.3 and 18.0 ± 6.9 days in the surviving 13 patients of the group 2 (P = .645 and P = .697, respectively).

CONCLUSIONS

With its shorter implantation time and reduced blood product requirement in the early postoperative period, the HM3 system was found to be safe and effective in ESHF treatment.

Exercise physiology in chronic mechanical circulatory support patients: vascular function and beyond

PURPOSE OF REVIEW

The majority of patients currently implanted with left ventricular assist devices have the expectation of support for more than 2 years. As a result, survival alone is no longer a sufficient distinctive for this technology, and there have been many studies within the last few years examining functional capacity and exercise outcomes.

RECENT FINDINGS

Despite strong evidence for functional class improvements and increases in simple measures of walking distance, there remains incomplete normalization of exercise capacity, even in the presence of markedly improved resting hemodynamics. Reasons for this remain unclear. Despite current pumps being run at a fixed speed, it is widely recognized that pump outputs significantly increase with exercise. The mechanism of this increase involves the interaction between preload, afterload, and the intrinsic pump function curves. The role of the residual heart function is also important in determining total cardiac output, as well as whether the aortic valve opens with exercise. Interactions with the vasculature, with skeletal muscle blood flow and the state of the autonomic nervous system are also likely to be important contributors to exercise performance.

SUMMARY

Further studies examining optimization of pump function with active pump speed modulation and options for optimization of the overall patient condition are likely to be needed to allow left ventricular assist devices to be used with the hope of full functional physiological recovery.

To ventricular assist devices or not: When is implantation of a ventricular assist device appropriate in advanced ambulatory heart failure?

Advanced heart failure has been traditionally treated via either heart transplantation, continuous inotropes, consideration for hospice and more recently via left ventricular assist devices (LVAD). Heart transplantation has been limited by organ availability and the futility of other options has thrust LVAD therapy into the mainstream of therapy for end stage heart failure. Improvements in technology and survival combined with improvements in the quality of life have made LVADs a viable option for many patients suffering from heart failure. The question of when to implant these devices in those patients with advanced, yet still ambulatory heart failure remains a controversial topic. We discuss the current state of LVAD therapy and the risk vs benefit of these devices in the treatment of heart failure.

Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement From the American Heart Association/American Stroke Association

The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidence-based care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payer-provider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.

Adaptation and coping in patients living with an LVAD: A metasynthesis

OBJECTIVE

To synthesize information supporting coping and adaptation of LVAD patients and to identify opportunities for future interventions.

BACKGROUND

Left Ventricular Assist Device (LVAD) patients demonstrate improvements in quality of life and functional status, but qualitative research has not been meaningfully integrated.

METHODS

Qualitative meta-synthesis using Lazarus and Folkmans' Transactional Model of stress and coping.

RESULTS

Four distinct stages of adaptation were identified: Pre-LVAD, Implant Hospitalization, Early Home Adaptation and Late Home Adaptation. Each stage includes tasks in physical, psychological and social domains. Two themes emerged: 1) Primary Appraisal: Every stage is a new challenge and 2) Secondary Appraisal: Routines are achievable, emotions are more difficult.

CONCLUSIONS

Emotional challenges including fear and anxiety related to life-limiting illness and changed social roles need to be honestly addressed. Individuals living with LVAD achieve a sense of independence, enjoy social interactions and meaningful activities through addressing practical and emotional problems to facilitate coping.

A Systematic Review of the Cost-Effectiveness of Long-Term Mechanical Circulatory Support

BACKGROUND

Mechanical circulatory support (MCS) is an option for the treatment of medically intractable end-stage heart failure. MCS therapy, however, is resource intensive.

OBJECTIVE

The purpose of this report was to systematically review the MCS cost-effectiveness literature as it pertains to the treatment of adult patients in end-stage heart failure.

METHODS

We conducted a systematic search and narrative review of available cost- effectiveness and cost-utility analyses of MCS in adult patients with end-stage heart failure.

RESULTS

Eleven studies analyzing the cost-effectiveness or cost-utility of MCS were identified. Seven studies focused on bridge to transplantation, three studies focused on destination therapy, and one study presented analyses of both strategies. Two articles evaluated the cost-effectiveness of the HeartMate II (Thoratec Corp., Pleasanton, CA). Incremental cost-effectiveness ratios between MCS and medical management ranged between $85,025 and $200,166 for bridge to transplantation and between $87,622 and $1,257,946 for destination therapy (2012 Canadian dollars per quality-adjusted life-year). Sensitivity analyses indicated that improvements in survival and quality of life and reductions in device and initial hospital-stay costs may improve the cost-effectiveness of MCS.

CONCLUSIONS

Current studies suggest that MCS is likely not cost-effective with reference to generally accepted or explicitly stated thresholds. Refined patient selection, complication rates, achieved quality of life, and device/surgical costs, however, could modify the cost-effectiveness of MCS.

The Experience of Family Caregivers of Patients With a Left Ventricular Assist Device

Objective:

The purpose of this review is to understand the experience of caregivers of patients with left ventricular assist device (LVAD) and to evaluate how health professionals can support them properly.

Background:

Left ventricular assist device can improve quality of life, enhance functional status, and prolong survival in patients with advanced heart failure. Nonetheless, LVAD can adversely influence quality of life for their family caregivers.

Methods:

An integrative literature review was conducted using scientific databases between January to March 2015.

Results:

A total of 15 studies are included in the final review. Three major themes emerged “emotional distress,” “responsibility,” and “coping strategies” that characterize family caregivers’ experiences with care of patients with LVAD.

Conclusion:

Health care providers should understand the pivotal role of caregivers in promoting and maintaining patients’ well-being and be able to help the caregiver to moderate the impact being overloaded. Research should be addressed to create interventions that motivate the caregivers to engage in activities that promote their health.

[Rehabilitation standards for follow-up treatment and rehabilitation of patients with ventricular assist device (VAD)]

The increasing use of ventricular assist devices (VADs) in terminal heart failure patients provides new challenges to cardiac rehabilitation physicians. Structured cardiac rehabilitation strategies are still poorly implemented for this special patient group. Clear guidance and more evidence for optimal modalities are needed. Thereby, attention has to be paid to specific aspects, such as psychological and social support and education (e.g., device management, INR self-management, drive-line care, and medication).In Germany, the post-implant treatment and rehabilitation of VAD Patients working group was founded in 2012. This working group has developed clear recommendations for the rehabilitation of VAD patients according to the available literature. All facets of VAD patients' rehabilitation are covered. The present paper is unique in Europe and represents a milestone to overcome the heterogeneity of VAD patient rehabilitation.

Psychosocial issues in ventricular assist device implantation and management

The primary goal of mechanical circulatory support (MCS) is to increase quantity and quality of life (QOL) in patients with systolic heart failure refractory to medical therapies. A key contributor to the success in MCS therapy is a comprehensive assessment of the candidate for device implantation. A crucial element of that assessment is an evaluation of the individual's psychosocial status, recommended by most current MCS guidelines. By focusing on criteria including drug, alcohol and tobacco abuse, ability to learn and problem solve, history of adherence to medical regimens, and adequate psychosocial support following implant, the team has an opportunity to create an individualized post-discharge plan that addresses identified gaps and optimizes the patient's likelihood for success. Information gathered also provides the team with a setting in which to discuss the patient's personal goals for the therapy and advanced care planning. We explore all of these issues and offer recommendations for approaching psychosocial assessment for MCS patients.

Patients' decision making process and expectations of a left ventricular assist device pre and post implantation

OBJECTIVES

To examine patients' pre-implantation decision-making and pre and post-implantation expectations of left ventricular assist devices (LVADs).

BACKGROUND

LVADs have been shown to improve both quantity and quality of life of patients living with Stage D heart failure (HF). However, they also pose significant risks.

METHODS

15 LVAD participants followed in a longitudinal study of Stage D HF patients were included in this thematic analysis.

RESULTS

Three themes were identified: no choice; I thought I would be doing better; I feel good, but now what. Evidence from pre-implantation to post-implantation suggested that patients' perceived expectations of quality of life improvement were not met.

CONCLUSIONS

In light of their declining health, most patients felt their only alternative to implantation was death. In the post-implantation period, patients expected greater improvements in their quality of life. Evidence based guidelines for discussions of goals of care, post-implant expectations, and palliative care are necessary.

Initial 3-year outcomes with left ventricular assist devices in a country with a nascent heart transplantation program

AIMS

The need for the left ventricular assist devices (LVAD) in patients with end-stage heart failure is well established, but prior to 2011, this was not available to patients in Kazakhstan. We describe the development of the sole LVAD programme in the context of a nascent heart transplantation programme and clinical outcomes for the first three years.

METHODS AND RESULTS

From November 2011 to November 2014, 146 patients underwent implantation of 152 VADs (approximately 50 devices implanted per year). We retrospectively analyzed data from 135 LVAD patients who received HeartMate II (n = 95) or HeartWare (n = 40) devices. In 75 patients LVAD was used as a bridge-to-transplantation and in 60 patients as destination therapy, but only 3 of 135 LVAD patients received heart transplant. Forty-three patients of the LVAD cohort had died by the end of the follow-up period. The mean time on LVAD was 466 ± 330 days (range 5-1200 days). Kaplan-Meier survival estimates for patients who continued on LVAD support were 93% after 1 month, 86% after 6 months and 77% after 12 months. The most common complications within the first 30 days after implant included right ventricular failure (n = 20, 1.85 events/patient-year), renal failure (n = 19, 1.76 events/patient-year) and bleeding (n = 33, 3.0 events/patient-year). Beyond 30 days adverse events included driveline infections (n = 46, 0.56 events/patient-year) and stroke (n = 33, 0.21 events/patient-year).

CONCLUSIONS

LVADs are an important therapeutic alternative to heart transplantation in the context of a developing heart transplant programme with outcomes that are comparable to those reported by other centres.

Beyond the VAD: Human Factors Engineering for Mechanically Assisted Circulation in the 21st Century

Thousands of ventricular assist devices (VADs) currently provide circulatory support to patients worldwide, and dozens of heart pump designs for adults and pediatric patients are under various stages of development in preparation for translation to clinical use. The successful bench-to-bedside development of a VAD involves a structured evaluation of possible system states, including human interaction with the device and auxiliary component usage in the hospital or home environment. In this study, we review the literature and present the current landscape of preclinical design and assessment, decision support tools and procedures, and patient-centered therapy. Gaps of knowledge are identified. The study findings support the need for more attention to user-centered design approaches for medical devices, such as mechanical circulatory assist systems, that specifically involve detailed qualitative and quantitative assessments of human-device interaction to mitigate risk and failure.

Survival and quality of life after extracorporeal life support for refractory cardiac arrest: A case series

OBJECTIVES

Extracorporeal life support (ECLS) is an emerging option to treat selected patients with cardiac arrest refractory to cardiopulmonary resuscitation (CPR). Our primary objective was to determine the mortality at 30 days and at hospital discharge among adult patients receiving veno-arterial ECLS for refractory cardiac arrest. Our secondary objectives were to determine the 1-year survival and the health-related quality of life, and to examine factors associated with 30-day mortality.

METHODS

In a retrospective, single-center investigation within a tertiary referral center, we analyzed the prospectively collected data of 49 patients rescued from refractory cardiac arrest through emergent implantation of ECLS (E-CPR) (18.1% of our overall ECLS activity, 2005-2013), implanted in-hospital and during ongoing external cardiac massage in all cases. A prospective follow-up with administration of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) questionnaire was performed.

RESULTS

The mean age was 47.6 ± 1.6 years; out-of-hospital cardiac arrest occurred in 12% of cases; average low-flow time was 47.2 ± 33 minutes; causes of cardiac arrest were heart disease (61.2%), trauma (14.3%), respiratory disease (4.1%), sepsis (2%), and miscellaneous (18.4%).

PRIMARY OBJECTIVE

Rates of survival at E-CPR explantation and at 30 days were 42.9% and 36.7%, respectively; brain death occurred in 24.5% of cases.

SECONDARY OBJECTIVES

Increased simplified acute physiology score; higher serum lactate levels and lower body temperature at the time of implantation were associated with 30-day mortality. Bridge to heart transplantation or implantation of a long-term ventricular assist device was performed in 8.2%. No deaths occurred during the follow-up after discharge (36.7% survival; average follow-up was 15.6 ± 19.2 months). The average Physical Component Summary and Mental Component Summary scores (SF-36 questionnaire) were, respectively, 45.2 ± 6.8 and 48.3 ± 7.7 among survivors.

CONCLUSIONS

Extracorporeal cardiopulmonary resuscitation is a viable treatment for selected patients with cardiac arrest refractory to CPR. In our series, approximately one third of rescued patients were alive at 6 months and presented quality-of-life scores comparable to those previously observed in patients treated with ECLS.

Learning self-care after left ventricular assist device implantation

The number of heart failure (HF) patients living with a left ventricular assist device (LVAD) as destination therapy is increasing. Successful long-term LVAD support includes a high degree of self-care by the patient and their caregiver, and also requires long-term support from a multidisciplinary team. All three components of self-care deserve special attention once an HF patient receives an LVAD, including activities regarding self-care maintenance (activities related both to the device and lifestyle), self-care monitoring (e.g., monitoring for complications or distress), and self-care management (e.g., handling alarms or coping with living with the device). For patients to perform optimal self-care once they are discharged, they need optimal education that focuses on knowledge and skills through a collaborative, adult learning approach.

Usability Testing of an Internet-Based e-Counseling Platform for Adults With Chronic Heart Failure

Background

Chronic heart failure (CHF) is a major cause of hospitalization and mortality. In order to maintain heart function and quality of life, patients with CHF need to follow recommended self-care guidelines (ie, eating a heart healthy diet, exercising regularly, taking medications as prescribed, monitoring their symptoms, and living a smoke-free life). Yet, adherence to self-care is poor. We have developed an Internet-based e-Counseling platform, Canadian e-Platform to Promote Behavioral Self-Management in Chronic Heart Failure (CHF-CePPORT), that aims to improve self-care adherence and quality of life in people with CHF. Before assessing the efficacy of this e-platform in a multisite, double-blind, randomized controlled trial, we evaluated the usability of the prototype website.

Objective

The objective of the study was to assess the usability of the CHF-CePPORT e-Counseling platform in terms of navigation, content, and layout.

Methods

CHF patients were purposively sampled from the Heart Function Clinic at the Peter Munk Cardiac Center, University Health Network, to participate in this study. We asked the consented participants to perform specific tasks on the website. These tasks included watching self-help videos and reviewing content as directed. Their interactions with the website were captured using the “think aloud” protocol. After completing the tasks, research personnel conducted a semi-structured interview with each participant to assess their experience with the website. Content analysis of the transcripts from the “think aloud” sessions and the interviews was conducted to identify themes related to navigation, content, and layout of the website. Descriptive statistics were used to summarize the satisfaction data.

Results

A total of 7 men and women (ages 39-77) participated in 2 iterative rounds of testing. Overall, all participants were very satisfied with the content and layout of the website. They reported that the content was helpful to their management of CHF and that it reflected their experiences in coping with CHF. The layout was professional and friendly. The use of videos made the learning process entertaining. However, they experienced many navigation errors in the first round of testing. For example, some participants were not sure how to navigate across a series of Web pages. Based on the experiences that were reported in the first round, we made several changes to the navigation structure. This included using large navigation buttons to direct users to each section and providing tutorial videos to familiarize users with our website. We assessed whether these changes improved user navigation in the second round of testing. The major finding is that participants made fewer navigation errors and they did not identify any new problems.

Conclusions

We found evidence to support the usability of our CHF-CePPORT e-Counseling platform. Our findings highlight the importance of a clear and easy-to-follow navigation structure on user experience.

Determinants of functional capacity after mitral valve annuloplasty or replacement for ischemic mitral regurgitation

OBJECTIVE

To identify the exercise echocardiographic determinants of long-term functional capacity, in patients with chronic ischemic mitral regurgitation, after restrictive mitral valve annuloplasty (RMA) or mitral valve replacement (MVR).

METHODS

We retrospectively analyzed 121 patients with significant chronic ischemic mitral regurgitation, who underwent RMA (n = 62) or MVR (n = 59), between 2005 and 2011. Preoperatively, all patients underwent a resting echocardiographic examination, and a 6-minute walking test (6-MWT) to measure distance. Resting and exercise stress echocardiography, and the 6-MWT were repeated at 41 ± 16.5 months.

RESULTS

After surgery, the 6-MWT distance significantly improved in the MVR group, and decreased in the RMA group (+37 ± 39 m vs -24 ± 49 m, respectively; P < .0001). Exercise indexed effective orifice area was significantly higher in the MVR, versus the RMA, group (MVR: change from 1.3 ± 0.2 cm(2)/m(2) to 1.5 ± 0.3 cm(2)/m(2); RMA: change from 1.1 ± 0.3 cm(2)/m(2) to 1.2 ± 0.3 cm(2)/m(2); P = .001). The mean mitral gradients significantly increased from rest to exercise, in both groups, but to a greater extent in the RMA group (change from 4.4 ± 1.4 to 11 ± 3.6 mm Hg; MVR: change from 4.3 ± 1.8 to 9 ± 3.5 mm Hg; P = .006). On multivariate analysis, MVR and exercise indexed effective orifice area were the main independent determinants of postoperative 6-MWT. In the RMA group, 25 patients experienced late mitral regurgitation recurrence, severe in 9 (14%) of them. The rate of postoperative cardiovascular events was significantly higher in the RMA group (21% vs MVR: 8%; P = .03). Follow-up survival was 83% in the RMA group and 88% in the MVR group (P = .54).

CONCLUSIONS

For chronic ischemic mitral regurgitation, MVR versus RMA was associated with better postoperative exercise hemodynamic performance and long-term functional capacity.

Left Ventricular Assist Device: Care On Inpatient Rehabilitation Facility

PURPOSE

Investigate the outcomes of patients admitted to an inpatient rehabilitation facility (IRF) after placement of a left ventricular assist device (LVAD).

DESIGN

Retrospective review of records.

METHOD

Authors reviewed records of patients admitted to the IRF after cardiac surgery or admission to the hospital with either acute myocardial infarction, congestive heart failure, or placement of an LVAD. The study reports improvement in function, length of stay (LOS), and location of discharge.

FINDINGS

The patients in the LVAD group made as much progress in terms of improvement in function as the other groups. None of the patients in the LVAD group required transfer back to medical or surgical units. All were discharged to home. Length of stay (LOS) of the LVAD group was not significantly longer than that of the other cardiac patients.

CONCLUSIONS

Patients who have had placement of an LVAD can be safely cared for in an IRF.

CLINICAL RELEVANCE

This paper provides information about the indications for LVAD, the nursing care of patients with an LVAD, and the outcomes of care in an IRF.

Clinical psychological and neuropsychological issues with left ventricular assist devices (LVADs)

BACKGROUND

Left ventricular assist devices (LVADs) are increasingly being used to treat patients in end-stage heart failure (HF) as bridge-to-transplantation, lifetime support or destination therapy. However, the importance of this newer technique for chronic cardiac support compared to heart transplantation is still open to discussion. To date, there are few studies that extensively explore the psychological and cognitive profiles of patient with ventricular assist devices (VADs).

METHODS

We studied the psychological aspects, quality of life (QOL) and cognitive profiles of 19 patients with HF before VAD implantation and then at two, five and 16 months post-implantation.

RESULTS

Our results showed that after VAD implantation, patients did not show any psychopathological problems such as anxiety and/or depression. More interestingly, despite the constant risk of neurological events determined by the continuous-blood-flow pump (CBFP), patients' cognitive functioning did not worsen. In fact, significant enhancements were observed over time.

CONCLUSIONS

Psychological and cognitive deficits are common in advanced HF and often worsen over time. Appropriately designed and randomized studies are needed to demonstrate whether earlier VAD implantation is warranted to arrest cognitive decline and encourage better post-implantation adaptation.

Quality of life and emotional distress early after left ventricular assist device implant: a mixed-method study

Patients who temporarily or permanently rely on left ventricular assist devices (LVADs) for end-stage heart failure face complex psychological, emotional, and relational problems. We conducted a mixed-method study to investigate quality of life, psychological symptoms, and emotional and cognitive reactions after LVAD implant. Twenty-six patients admitted to cardiac rehabilitation were administered quality of life questionnaires (Short Form 36 of the Medical Outcomes Study and Minnesota Living with Heart Failure Questionnaire), the Hospital Anxiety and Depression Scale, and the Coping Orientation for Problem Experiences inventory, and underwent three in-depth unstructured interviews within 2 months after LVAD implant. Quality of life assessment (Short Form 36) documented persistently low physical scores whereas mental component scores almost achieved normative values. Clinically relevant depression and anxiety were observed in 18 and 18% of patients, respectively; avoidant coping scores correlated significantly with both depression and anxiety (Pearson correlation coefficients 0.732, P < 0.001 and 0.764, P < 0.001, respectively). From qualitative interviews, factors that impacted on LVAD acceptance included: device type, disease experience during transplant waiting, nature of the assisted organ, quality of patient-doctor communication, the opportunity of sharing the experience, and recipient's psychological characteristics. Quality of life improves early after LVAD implant, but emotional distress may remain high. A multidimensional approach that takes into account patients' psychological characteristics should be pursued to enhance LVAD acceptance.

Right ventricular unloading and respiratory support with a wearable artificial pump-lung in an ovine model

BACKGROUND

Device availability of mechanical circulatory or respiratory support to the right heart has been limited. The purpose of this study was to investigate the effect of right heart unloading and respiratory support with a wearable integrated artificial pump-lung (APL).

METHODS

The APL device was placed surgically between the right atrium and pulmonary artery in 7 sheep. Anti-coagulation was performed with heparin infusion. The device's ability to unload the right ventricle (RV) was investigated by echocardiograms and right heart catheterization at different bypass flow rates. Hemodynamics and echocardiographic data were evaluated. APL flow and gas transfer rates were also measured at different device speeds.

RESULTS

Hemodynamics remained stable during APL support. There was no significant change in systemic blood pressure and cardiac index. Central venous pressure, RV pressure, RV end-diastolic dimension and RV ejection fraction were significantly decreased when APL device flow rate approached 2 liters/min. Linear regression showed significant correlative trends between the hemodynamic and cardiac indices and device speed. The oxygen transfer rate increased with device speed. The oxygen saturation from the APL outlet was fully saturated (>95%) during support. The impact of APL support on blood elements (plasma free hemoglobin and platelet activation) was minimal.

CONCLUSIONS

APL device support significantly unloaded the RV with increasing device speed. The device also provided stable hemodynamics and respiratory support in terms of blood flow and oxygen transfer. The right heart unloading performance of this wearable device needs to be evaluated further in an animal model of right heart failure with long-term support.

Predictors of changes in health status between and within patients 12 months post left ventricular assist device implantation

BACKGROUND

Improving patient-reported outcomes (e.g. health status) has become an important goal in left ventricular assist device (LVAD) therapy, in addition to reducing mortality and morbidity. We examined predictors of changes in health status scores between and within patients 12 months post LVAD implantation.

METHODS

Health status [Kansas City Cardiomyopathy Questionnaire (KCCQ); Short-Form 12 (SF-12)] were assessed at 3-4 weeks after implantation, and at 3, 6 and 12 months follow up in 54 LVAD patients (74% men; mean age 54 ± 9 years).

RESULTS

Patients experienced significant improvements in health status between baseline and 3 months follow-up as assessed by the KCCQ (clinical summary score: F = 33.49, P < 0.001; overall summary score: F = 31.13, P < 0.001) and the SF-12 (physical component score: F = 31.59, P < 0.001; mental component score: F = 21.77, P < 0.001), but not between 3 months and 12 months follow-up (P > 0.05 for all). Higher scores on anxiety and depression over time, older age, lower ejection fraction, and more co-morbidity were associated with poorer health status scores on one or both of the KCCQ and SF-12 subscales. The majority of the between-patient variance of the mental component summary scores (82.6%), but not the KCCQ overall summary score (41.9%), KCCQ clinical summary score (36.2%) and physical component summary scores (23.2%), was explained by the sociodemographic, clinical and psychological factors.

CONCLUSION

The majority of LVAD patients show a significant improvement in health status after LVAD implantation. However, there are large differences in individual health status score trajectories which are only partly explained by measures of disease severity pre-LVAD, co-morbidity and psychological stress.

LVAD: Left ventricular assist devices for end-stage heart failure

Heart failure affects more than 5 million Americans with approximately 200,000 patients in end-stage disease that has failed traditional treatment. Historically, the only option for treatment was a heart transplant until left ventricular assist devices offered another option.

Left ventricular assist devices in patients with end-stage heart failure: suggestion of an alternative treatment based on clinically well-known concepts

Encouraging results were obtained by using left ventricular assist devices (LVADs) in patients with end-stage heart failure (HF) that exhibits extremely high mortality and who were not candidates for heart transplantation. By using this so-called destination therapy (DT), a substantial percentage of these patients achieved sufficient improvement in cardiac function to permit the explantation of the device. The combination of mechanical and pharmacological therapy increased the frequency and durability of myocardial recovery as compared with other therapeutic approaches. Although cardiac transplantation, LVADs, and cardiac resynchronization therapy have provided a major advance in DT, their limitations stimulate the search for alternative therapies. We discuss the limitations of these 3 treatment options for end-stage HF. Also, we propose and discuss the possible advantages of a new intracorporeal procedure that works continuously as intraaortic balloon counterpulsation without an extracorporeal or intracorporeal computer-controlled mechanism.

Psychological distress in patients with a left ventricular assist device and their partners: an exploratory study

BACKGROUND

Left ventricular assist device (LVAD) therapy is increasingly used in patients with advanced heart failure, and may have a significant psychological impact on both patients and their partners. Hence, we examined the distress levels of LVAD patients and their partners.

METHODS

Anxiety, depression and post-traumatic stress disorder (PTSD) were assessed at 3-4 weeks after implantation, and at 3 and 6 months follow-up in 33 LVAD patients (73% men; mean age=54±10 years) and 33 partners (27% men; mean age=54±11 years).

RESULTS

The prevalence of anxiety in LVAD partners was significantly higher compared to LVAD patients at baseline (48% vs. 23%, p=0.03) and 3 months follow-up (44% vs. 15%, p=0.02), but not at 6 months follow-up (p=0.43). No differences were found for depression and PTSD (ps>0.05). Scores between the LVAD patients and partners showed only a significant correlation at baseline between the anxiety, depression and PTSD score of the patient and the depression score of the partner (r anx=0.40, p=0.04; rdep=.40, p=0.04; r PSTD=0.46, p=0.05). Multivariable analyses showed no significant association between the role (patient vs. partner) and anxiety, depression and PTSD over time after correction for age, gender and clinical covariates. However, after correction for Type D personality and the use of psychotropic medication the LVAD partners showed significantly higher anxiety (F=6.95, p=0.01) and depression (F=3.94, p=0.04) scores over time compared to LVAD patients.

CONCLUSION

LVAD partners had significantly higher levels of anxiety than LVAD patients. Emotional distress of LVAD partners should gain more attention, as partners are an essential source of support for LVAD patients.

Rotary blood pumps as definitive treatment for severe heart failure

Rotary blood pumps are increasingly recognized as mainstream therapy for severely symptomatic heart failure. Carefully targeted refinements in patient selection and postoperative care have substantially reduced the adverse event burden. These improvements translate into better survival and quality of life in comparison with medical management. Medium-term outcomes now compete favorably with cardiac transplantation, although evidence-based outcome data indicate that transplant and ‘lifetime’ left ventricular-assist device (LVAD) candidates are fundamentally different. Significant challenges remain in relation to neurological injury and right heart failure, which may continue to limit exercise capacity. In the meantime, both physician awareness and patient access to LVAD technology remain limited. The debate is rarely between cardiac transplant or lifetime LVAD. It should focus on the choice between pump versus palliative care for the thousands of patients of all age groups who are judged ineligible for transplantation. Comprehensive healthcare systems must consider contemporary evidence and provide the most symptomatic of heart failure patients with effective care. Cardiac resynchronization therapy is no longer the ceiling for this.