Readmissions after continuous flow left ventricular assist device implantation

Relationship between muscle strength and rehospitalization in ventricular assist device patients

We examined the relationship between leg extensor muscle strength (LEMS) at discharge and rehospitalization within 1 year in patients with a newly implanted ventricular assist device (VAD). This study included 28 patients who had received a VAD at our institution between October 2013 and February 2019, all of whom had been discharged for 1 year. The patients were divided into two groups according to their LEMS at discharge (higher strength [group H] and lower strength [group L]), based on the median value of the 55.2 kg-force (kgf)/body weight (BW) equation. Exercise performance parameters (e.g., grip strength, 6-min walk distance, and peak VO₂) and laboratory data concerning nutritional status were also collected. Nine patients (64.3%) in group L were rehospitalized within 1 year after discharge. The rehospitalization rate was significantly higher in group L than group H (p = 0.020). Compared with discharge, patients exhibited higher grip strength (56.3 vs. 48.6 kg/BW, respectively; p = 0.011), 6-min walk distances (588 vs. 470 m, respectively; p = 0.002), and peak VO₂ (15.4 vs. 11.9 mL/min/kg, respectively; p < 0.001) at 1 year after discharge. However, the LEMS (57.4 vs. 58.0 kgf/BW, respectively; p = 0.798) did not increase after discharge in VAD patients who avoided rehospitalization. LEMS at discharge was associated with rehospitalization after VAD surgery; a high LEMS improves the likelihood of avoiding rehospitalization.

A varied approach to left ventricular assist device follow-up improves cost-effectiveness

BACKGROUND

Left ventricular assist device (LVAD) implantation improves outcomes in advanced heart failure, however, the optimal frequency of outpatient assessments to improve cost-effectiveness and potentially avert readmissions is unclear.

METHODS

To test if varying the frequency of follow-up after LVAD implantation reduces readmissions and improves cost-effectiveness, a less intensive follow-up (LIFU) strategy with scheduled visits at 1 month and then every 6 months was compared to an intensive follow-up (IFU) group with scheduled visits at 1, 2, and 4 weeks, and then every 3 months post-implant. We developed a decision-tree model to evaluate the cost-effectiveness of different follow-up schedules at 3, 6, and 12-months. The readmission rates for LIFU and IFU, along with the associated costs, were estimated using data from the IBM MarketScan Commercial Claims Databases (2015-2018). A total of 349 patients were enrolled, with 193 and 156 in the IFU and LIFU groups.

RESULTS

Patients with IFU were found to have a lower risk for readmission at 3 months (HR: 0.69, 95% confidence interval (CI): 0.60-0.79), but this difference diminished overtime at 6 months (HR: 0.84, 95% CI: 0.73-0.96) and 12 months (HR: 0.94, 95% CI: 0.83-1.06). The incremental net benefit of IFU, when compared with LIFU, is greatest in the first 3 months and also diminishes over time (3 months: $19616, 6 months $9257, 12 months $717).

CONCLUSIONS

An initial IFU strategy, followed by a period of de-escalation at the 6-month post-implant mark in lower-risk patients, may be a more cost-effective strategy to provide follow-up care while not predisposing patients to a higher risk of readmission.

Safety and feasibility of hemodynamic pulmonary artery pressure monitoring using the CardioMEMS device in LVAD management

BACKGROUND

There is a clinical need for additional remote tools to improve left ventricular assist device (LVAD) patient management. The aim of this pilot concept study was to assess the safety and feasibility of optimizing patient management with add-on remote hemodynamic monitoring using the CardioMEMS in LVAD patients during different treatment stages.

METHODS

Ten consecutive patients accepted and clinically ready for (semi-) elective HeartMate 3 LVAD surgery were included. All patients received a CardioMEMS to optimize filling pressure before surgery. Patients were categorized into those with normal mean pulmonary artery pressure (mPAP) (≤25 mmHg, n = 4) or elevated mPAP (>25 mmHg, n = 6), and compared to a historical cohort (n = 20). Endpoints were CardioMEMS device safety and a combined endpoint of all-cause mortality, acute kidney injury, renal replacement therapy and/or right ventricular failure at 1-year follow-up. Additionally, we investigated hospital-free survival and improvement in quality of life (QoL) and exercise tolerance.

RESULTS

No safety issues or signal interferences were observed. The combined endpoint occurred in 60% of historical controls, 0% in normal and 83% in elevated mPAP group. Post-discharge, the hospital-free survival was significantly better, and the QoL improved more in the normal compared to the elevated mPAP group.

CONCLUSION

Remote hemodynamic monitoring in LVAD patients is safe and feasible with the CardioMEMS, which could be used to identify patients at elevated risk of complications as well as optimize patient management remotely during the out-patient phase with less frequent hospitalizations. Larger pivotal studies are warranted to test the hypothesis generated from this concept study.

The analysis of unplanned readmissions after left ventricular assist device implantation as bridge-to-transplant

Background

In this study, we aimed to investigate frequency, patterns, etiologies, and costs of unplanned readmissions after left ventricular assist device implantation.

Methods

Between April 2012 and September 2016, 99 unplanned readmissions of a total of 50 consecutive bridge-to-transplant patients (45 males, 5 females; mean age 46.9±10.3 years; range, 19 to 67 years) who were successfully discharged after left ventricular assist device implantation were retrospectively analyzed. Patient demographic data, hemodynamic measurements before implantation, and readmissions after discharge were recorded. Hospitalizations due to major problems which were unable to be managed in routine outpatient clinic were accepted as unplanned readmissions. Survival analysis was performed.

Results

The readmission rate was 1.7 per year after discharge. Survival of patients who were readmitted within the first 90 days was found to be significantly lower than those without early readmission. The most common reasons of readmissions during follow-up were major infection (23.2%), neurological dysfunction (22.2%), cardiac causes (12.1%), bleeding (11.1%), and device malfunction (10.1%). Neurological dysfunctions (82,005 USD) and device malfunctions (73,300 USD) caused the highest economic burden.

Conclusion

Among patients with a left ventricular assist device, hospital readmissions are common. Development of preventive strategies as well as effective treatment methods focused on longterm adverse events is critical to reduce the frequency and costs of hospital readmissions.

Clinical outcomes of inpatient cardiac rehabilitation for patients with treated left ventricular assist device in Korea: 1-year follow-up

In Korea, the first patient with a left ventricular assist device (LVAD) for destination therapy had successful implantation of a continuous-flow model in 2012. We investigated the safety and efficacy of exercise therapy with LVAD implantation 15 Korean patients. We retrospectively reviewed 15 patients (mean age, 67.4±11.6 years; 10 males, 5 female, left ventricular ejection fraction 23.6%±7.1%), including 4 with implanted continuous-flow and 11 an axial-flow LVAD. The New York Heart Association functional classification, ejection fraction, and quality of life were obtained. Survival rate, adverse events, admission rates, and enrollment rates in cardiac rehabilitation were investigated. Survival at 6 and 12 months was 100% and 89%, respectively. The New York Heart Association functional classification improved from 3.4±0.5 to 2.3±0.05 at 12 months postoperatively (P<0.0001). The ejection fraction significantly increased from 23.6%±7.2% on the preoperative day to 35.4%±14.2% at 1 year (P<0.0018). The quality of life was also improved at 1 year (P<0.0001). The most common adverse events were bleeding (56%) and dyspnea (44%). The number of admissions was 3.2 per patient-year. LVAD therapy is a safe and effective treatment option with exercise intervention for Korean patients waiting for heart transplantation or those who were ineligible for heart transplantation. A larger study with longer follow-up is needed to determine details clinical outcomes after LVAD.

The Rehabilitation of Patients With Advanced Heart Failure After Left Ventricular Assist Device Placement: A Narrative Review

Because more patients with advanced heart failure are receiving a left ventricular assist device (LVAD) as destination therapy or a bridge to transplantation, there is increasing attention on functional outcomes and quality of life after LVAD implantation. Rehabilitation providers in the acute inpatient rehabilitation setting increasingly will treat patients with an LVAD and should understand the exercise physiology, medical management, rehabilitation considerations, and outcomes after rehabilitation for patients with an LVAD. The purpose of this article is to provide the physiatrist with a comprehensive understanding of the rehabilitation of patients with advanced heart failure and LVAD implantation. Changes in relevant organ system physiology and exercise physiology after LVAD are summarized. Safety of rehabilitation and program considerations for acute inpatient rehabilitation are reviewed. Recommendations for medical management and prevention of secondary complications seen in patients with an LVAD are outlined. A discussion of outcomes after acute inpatient rehabilitation, the dual diagnosis of stroke and LVAD placement, and long-term cognitive, functional, and quality-of-life outcomes after LVAD placement is presented.

An Urban 9-1-1 System's Experience with Left Ventricular Assist Device Patients

Background: Left ventricular assist devices (LVADs) are used with increasing frequency and left in place for longer periods of time. Prior publications have focused on the mechanics of troubleshooting the device itself. We aim to describe the epidemiology of LVAD patient presentations to emergency medical services (EMS), prehospital assessments and interventions, and hospital outcomes. Methods: This is a retrospective chart review of known LVAD patients that belong to a single academic center's heart failure program who activated the 9-1-1 system and were transported by an urban EMS system to one of the center's 2 emergency departments between January 2012 and December 2015. Identifying demographics were used to query the electronic medical record of the responding city fire agency and contracted transporting ambulance service. Two reviewers abstracted prehospital chief complaint, vital signs, assessments, and interventions. Emergency department and hospital outcomes were retrieved separately. Results: From January 2012 to December 2015, 15 LVAD patients were transported 16 times. The most common prehospital chief complaint was weakness (7/16), followed by chest pain (3/16). Of the 7 patients presenting with weakness, one was diagnosed with a stroke in the emergency department. Another patient was diagnosed with subarachnoid hemorrhage and expired during hospital admission. This was the only death in the cohort. The most common hospital diagnosis was GI bleed (3/16). The overall admission rate was 87.5% (14/16). Conclusions: EMS interactions with LVAD patients are infrequent but have high rates of admission and incidence of life-threatening diagnoses. The most common prehospital presenting symptoms were weakness and chest pain, and most prehospital interactions did not require LVAD-specific interventions. In addition to acquiring technical knowledge regarding LVADs, EMS providers should be aware of non-device-related complications including intracranial and GI bleeding and take this into account during their assessment.

Telemonitoring of left-ventricular assist device patients-current status and future challenges

E-health, especially telemedicine, has undergone a remarkably dynamic development over the past few years. Most experience is currently in the field of telemedical care for heart failure (HF) patients. However, HF patients with an implanted left-ventricular assist device (LVAD) have been more or less excluded from consistent telemonitoring until now. And yet, continual monitoring would be very significant for this patient group because of the complexity of its aftercare, requiring steady control of various parameters (device-related parameters, vital parameters, coagulation parameters, etc.). With timely action, severe and costly complications like pump thromboses and driveline infections could be detected early on or even avoided completely. This paper describes the potential of telemonitoring in LVAD patients, as well as its first clinical implementation according to the available literature. It also describes the requirements for a complete telemonitoring of LVAD patients, facilitating the advancement of this form of continual monitoring to a clinical standard which would increase the quality of aftercare for this very special patient collective enormously.