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Mitra A, Siddique A. Tricuspid regurgitation in the setting of LVAD support. Front Cardiovasc Med 2023; 10:1090150. [PMID: 37304950 PMCID: PMC10250620 DOI: 10.3389/fcvm.2023.1090150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Tricuspid valve regurgitation (TR) is a common complication of end-stage heart failure. Increased pulmonary venous pressures caused by left ventricular (LV) dysfunction can result in a progressive dilation of the right ventricle and tricuspid valve annulus, resulting in functional TR. Here, we review what is known about TR in the setting of severe LV dysfunction necessitating long-term mechanical support with left ventricular assist devices (LVADs), including the occurrence of significant TR, its pathophysiology, and natural history. We examine the impact of uncorrected TR on LVAD outcomes and the impact of tricuspid valve interventions at the time of LVAD placement, revealing that TR frequently improves after LVAD placement with or without concomitant tricuspid valve intervention such that the benefit of concomitant intervention remains controversial. We summarize the current evidence on which to base medical decisions and provide recommendations for future directions of study to address outstanding questions in the field.
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Affiliation(s)
- Ananya Mitra
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, United States
| | - Aleem Siddique
- Division of Cardiothoracic Surgery, Department of Surgery,University of Nebraska Medical Center, Omaha, NE, United States
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2
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Segev A, Lavee J, Kassif Y, Shemesh Y, Kogan A, Freimark D, Morgan A, Lotan D, Itelman E, Grupper A. Effect of levosimendan infusion prior to left ventricular assist device implantation on right ventricular failure. J Cardiothorac Surg 2022; 17:158. [PMID: 35710438 PMCID: PMC9205013 DOI: 10.1186/s13019-022-01915-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Investigate the safety and efficacy of preoperative levosimendan in patients undergoing left ventricular assist device (LVAD) implantation.
Methods Consecutive patients who received LVADs (HeartMate-2, 3, HVAD) in a single tertiary medical center (2012–2018). INTERMACS profile 1 patients were excluded. The primary outcome was post-LVAD right ventricular failure (RVF) and inhospital mortality rates. The secondary outcomes included other clinical, echocardiographic and hemodynamic parameters at follow-up. Results Final cohort consisted of 62 patients (40[65%] in the levosimendan group and 22[35%] in the no-levosimendan group). Post-operative RVF rate and inotrope or ventilation support time were similar in the levosimendan and no-levosimendan groups (7.5% vs. 13.6%; P = 0.43, median of 51 vs. 72 h; P = 0.41 and 24 vs. 27 h; P = 0.19, respectively). Length of hospitalization, both total and in the intensive care unit, was not statistically significant (median days of 13 vs. 16; P = 0.34, and 3 vs. 4; P = 0.44, respectively). Post-operative laboratory and echocardiographic parameters and in-hospital complication rate did not differ between the groups, despite worse baseline clinical parameters in the Levosimendan group. There was no significant difference in the in-hospital and long term mortality rate (2.5% vs. 4.5%; P > 0.999 and 10% vs. 27.3% respectively; P = 0.64). Conclusions Levosimendan infusion prior to LVAD implantation was safe and associated with comparable results without significant improved post-operative outcomes, including RVF. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-01915-6.
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Affiliation(s)
- Amitai Segev
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Jacob Lavee
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yigal Kassif
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel
| | - Yedida Shemesh
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel
| | - Alexander Kogan
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel
| | - Dov Freimark
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Morgan
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel
| | - Dor Lotan
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Edward Itelman
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel
| | - Avishay Grupper
- Cardiovascular Division, Sheba Medical Center, Tel Hashomer, Sheba Rd. 2, Ramat-Gan, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hollander SA, Kaufman BD, Bui C, Gregori B, Murray JM, Sacks L, Ryan KR, Ma M, Rosenthal DN, Char D. Compassionate Deactivation of Pediatric Ventricular Assist Devices: A Review of 14 Cases. J Pain Symptom Manage 2021; 62:523-528. [PMID: 33910026 DOI: 10.1016/j.jpainsymman.2021.01.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/21/2021] [Accepted: 01/27/2021] [Indexed: 11/16/2022]
Abstract
CONTEXT Compassionate deactivation (CD) of ventricular assist device (VAD) support is a recognized option for children when the burden of therapy outweighs the benefits. OBJECTIVES To describe the prevalence, indications, and outcomes of CD of children supported by VADs at the end of life. METHODS Review of cases of CD at our institution between 2011 and 2020. To distinguish CD from other situations where VAD support is discontinued, patients were excluded from the study if they died during resuscitation (including extracorporeal membrane oxygenation), experienced brain or circulatory death prior to deactivation, or experienced a non-survivable brain injury likely to result in imminent death regardless of VAD status. RESULTS Of 24 deaths on VAD, 14 (58%) were CD. Median age was 5.7 (interquartile range (IQR) 0.6, 11.6) years; 6 (43%) had congenital heart disease; 4 (29%) were on a device that can be used outside of the hospital. CD occurred after 40 (IQR: 26, 75) days of support; none while active transplant candidates. CD discussions were initiated by the caregiver in 6 (43%) cases, with the remainder initiated by a medical provider. Reasons for CD were multifactorial, including end-organ injury, infection, and stroke. CD occurred with endotracheal extubation and/or discontinuation of inotropes in 12 (86%) cases, and death occurred within 10 (IQR: 4, 23) minutes of CD. CONCLUSION CD is the mode of death in more than half of our VAD non-survivors and is pursued for reasons primarily related to noncardiac events. Caregivers and providers both initiate CD discussions. Ventilatory and inotropic support is often withdrawn at time of CD with ensuing death.
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Affiliation(s)
- Seth A Hollander
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA.
| | - Beth D Kaufman
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Christine Bui
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Bianca Gregori
- Department of Social Work, Lucile Packard Children's Hospital Stanford (B.G.), Palo Alto, California, USA
| | - Jenna M Murray
- Solid Organ Transplant Services, Lucile Packard Children's Hospital Stanford (J.M.M), Palo Alto, California, USA
| | - Loren Sacks
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Kathleen R Ryan
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University School of Medicine (M.M.), Palo Alto, California, USA
| | - David N Rosenthal
- Department of Pediatrics (Cardiology), Stanford University School of Medicine (S.A.H., B.D.K., C.B., L.S., K.R.R., D.N.R.), Palo Alto, California, USA
| | - Danton Char
- Department of Anesthesia, Stanford University School of Medicine (D.C.), Palo Alto, California, USA
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Mulzer J, Krastev H, Hoermandinger C, Meyer A, Haese T, Stein J, Müller M, Schoenrath F, Knosalla C, Starck C, Falk V, Potapov E, Knierim J. Development of tricuspid regurgitation and right ventricular performance after implantation of centrifugal left ventricular assist devices. Ann Cardiothorac Surg 2021; 10:364-374. [PMID: 34159117 DOI: 10.21037/acs-2020-cfmcs-fs-0215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Tricuspid regurgitation (TR) after left ventricular assist device (LVAD) implantation is associated with a poor prognosis. This study evaluates the development of TR and right ventricular (RV) performance after LVAD implantation. Methods Retrospective analysis of patients who underwent LVAD implantation between March 2018 and June 2019. Patients who underwent concomitant tricuspid valve surgery and patients with congenital heart disease were excluded. Results A total of 155 patients underwent LVAD implantation. Fourteen patients were excluded. Of the remaining patients, thirty-one died during the first six months, six were lost to follow-up and two underwent transplantation. 102 patients presented at 6.3 months (5.8 to 7.0). Patients were supported with HeartWare HVAD (74%) or HeartMate 3 (26%). 50.4% were rated as INTERMACS profile 1 or 2. At six months, systolic pulmonary artery pressure dropped from 36 to 21 mmHg (P<0.001). Tricuspid annular plane systolic excursion decreased from 17.3 to 14.3 mm (P<0.001), RV fractional area change did not change (P=0.839). Twenty-two patients (22%) presented with moderate-to-severe or severe (ms-s) TR pre-operatively. Of these, eighteen (81%) showed improvement to ≤ moderate TR. At follow-up twelve patients presented with ms-s TR. Of these, only four patients (33%) had been diagnosed with ms-s TR pre-operatively. There were no differences in pre-operative echocardiographic or clinical parameters between the twelve patients with ms-s late TR and the other ninety patients in the cohort. Conclusions TR can show an impressive improvement with LVAD support. Longitudinal RV function decreases; this appears to be compensated by transverse shortening. Late TR can develop independently from pre-operative parameters including TR.
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Affiliation(s)
- Johanna Mulzer
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Hristo Krastev
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | | | - Alexander Meyer
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | | | | | - Marcus Müller
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Felix Schoenrath
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christoph Knosalla
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christoph Starck
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Volkmar Falk
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiothoracic Surgery, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Eidgenössiche Technische Hochschule Zürich, Department of Health Sciences and Technology, Translational Cardiovascular Technology, Zurich, Switzerland
| | - Evgenij Potapov
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
| | - Jan Knierim
- German Heart Center Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
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Using existing technology better: Improving outcomes with the HeartWare left ventricular assist device. Int J Cardiol 2021; 331:35-39. [PMID: 33529660 DOI: 10.1016/j.ijcard.2021.01.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The HeartWare left ventricular assist device has been in use for over 12 years. We sought to determine how outcomes at our centre have improved over time. METHODS Review of electronic hospital records at the Freeman Hospital, Newcastle upon Tyne, United Kingdom. RESULTS A total of 255 first time adult implants were divided into 2 eras: Era 1: 2009-2015 (N = 154) and Era 2: 2016-2020 (N = 101). We prospectively aimed to avoid higher risk Intermacs Classifications in Era 2, which resulted in significant changes in Intermacs class to lower risk in Era 2 (P < 0.001). There was a significant improvement in survival in Era 2, with 1 year survival increasing from 70 to 80% (P < 0.05). This was particularly associated with lower 30 day mortality in Era 2 (1.7 ± 2.3 vs 15.5 ± 7%, P < 0.005). This was associated with better right ventricular function in Era 2, and there was a trend to more temporary right ventricular assist devices used in Era 2 (28 ± 13 vs 12 ± 14%, P = 0.06). Deaths from intracranial haemorrhage, sepsis and right heart failure were unchanged between eras, though there was a trend towards less deaths in Era 2 from combined thromboses deaths (stroke and device thrombosis; 3.3 ± 5.4 vs 11.1 ± 7.4%, P = 0.07). CONCLUSIONS Better patient selection in association with more use of temporary right ventricular assist support has resulted in a significant improvement in survival. Intracranial haemorrhage, sepsis and right heart failure remain significant problems.
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Zinoviev R, Lippincott CK, Keller SC, Gilotra NA. In Full Flow: Left Ventricular Assist Device Infections in the Modern Era. Open Forum Infect Dis 2020; 7:ofaa124. [PMID: 32405511 PMCID: PMC7209633 DOI: 10.1093/ofid/ofaa124] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/14/2020] [Indexed: 12/20/2022] Open
Abstract
With the rising prevalence of heart disease in the United States, there is increasing reliance on durable mechanical circulatory support (MCS) to treat patients with end-stage heart failure. Left ventricular assist devices (LVADs), the most common form of durable MCS, are implanted mechanical pumps that connect to an external power source through a transcutaneous driveline. First-generation LVADs were bulky, pulsatile pumps that were frequently complicated by infection. Second-generation LVADs have an improved design, though infection remains a common and serious complication due to the inherent nature of implanted MCS. Infections can affect any component of the LVAD, with driveline infections being the most common. LVAD infections carry significant morbidity and mortality for LVAD patients. Therefore, it is paramount for the multidisciplinary team of clinicians caring for these patients to be familiar with this complication. We review the epidemiology, prevention, diagnosis, treatment, and outcomes of LVAD infections.
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Affiliation(s)
- Radoslav Zinoviev
- Department of Internal Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Christopher K Lippincott
- Department of Medicine - Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Sara C Keller
- Department of Medicine - Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Nisha A Gilotra
- Department of Medicine - Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Jabagi H, Ruel M, Sun LY. Can Biomarkers Provide Right Ventricular-Specific Prognostication in the Perioperative Setting? J Card Fail 2019; 26:776-780. [PMID: 31539620 DOI: 10.1016/j.cardfail.2019.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 09/05/2019] [Accepted: 09/07/2019] [Indexed: 01/11/2023]
Abstract
Since the introduction of biomarkers in the late 1980s, considerable research has been dedicated to their validation and application. As a result, many biomarkers are now commonly used in clinical practice. However, the role of biomarkers in the prediction of right ventricular failure (RVF) and in the prognostication for patients with RVF remains underexplored. Barriers include a lack of awareness of the importance of right ventricular function, especially in the perioperative setting, as well as a lack of reproducible means to assess right ventricular function in this setting. We provide an overview of biomarkers with right ventricular prognostic capabilities that could be further explored in patients expecting cardiac surgery, who are notoriously susceptible to developing RVF. We discuss biomarkers' mechanistic pathways and highlight their potential strengths and weaknesses in use in research and clinical care.
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Affiliation(s)
- Habib Jabagi
- Division of Cardiac Surgery, University of Ottawa Heart Institute
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute
| | - Louise Y Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute; School of Epidemiology and Public Health, University of Ottawa.
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8
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End of life for patients with left ventricular assist devices: Insights from INTERMACS. J Heart Lung Transplant 2019; 38:374-381. [DOI: 10.1016/j.healun.2018.12.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/26/2018] [Accepted: 12/12/2018] [Indexed: 11/23/2022] Open
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9
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Quality of death after left ventricular assist device implantation: More questions than answers. J Heart Lung Transplant 2019; 38:382-384. [PMID: 30765305 DOI: 10.1016/j.healun.2019.01.1307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/22/2019] [Indexed: 11/21/2022] Open
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Gaffey AC, Chen CW, Chung JJ, Han J, Bermudez CA, Wald J, Atluri P. Is there a difference in bleeding after left ventricular assist device implant: centrifugal versus axial? J Cardiothorac Surg 2018; 13:22. [PMID: 29433532 PMCID: PMC5810067 DOI: 10.1186/s13019-018-0703-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 01/22/2018] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Continuous-flow left ventricular assist devices (CF-LVAD) have become the standard of care for patients with end stage heart failure. Device reliability has increased, bringing the potential for VAD, compared to transplant, into debate. However, complications continue to limit VADs as first line therapy. Bleeding is a major morbidity. A debate exists as to the difference in bleeding profile between the major centrifugal and axial flow devices. We hypothesized that there would be similar adverse bleeding event profiles between the 2 major CF-LVADs. METHODS We retrospectively investigated isolated CF LVADs performed at our institution between July 2010 and July 2015: HeartMateII (HMII, n = 105) and HeartWare (HVAD, n = 34). We reviewed demographic, perioperative and short- and long-term outcomes. RESULTS There was no significant difference in demographics or comorbidities. There was a low incidence of gastrointestinal (GI) bleed 3.9% in HMII and 2.9% in HVAD (p = 0.78). Preoperatively, the cohorts did not differ in coagulation measures (p = 0.95). Within the post-operative period, there was no difference in product transfusion: red blood cells (p = 0.10), fresh frozen plasma (p = 0.19), and platelets (p = 0.89). Post-operatively, a higher but not significantly different number of HMII patients returned to the operating room for bleeding (n = 27) compared to HVAD (n = 6, p = 0.35). There was no difference in rates of stroke (p = 0.65), re-intubation (p = 0.60), driveline infection (p = 0.05), and GI bleeding (p = 0.31). The patients had equivalent ICU LOS (p = 0.86) and index hospitalization LOS (p = 0.59). CONCLUSION We found no difference in the rate of bleeding complications between the current commercially available axial and centrifugal flow devices.
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Affiliation(s)
- Ann C Gaffey
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA.
| | - Carol W Chen
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Jennifer J Chung
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Jason Han
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Joyce Wald
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Silverstein 6, 3400 Spruce St, Philadelphia, PA, 19104, USA
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Dunlay SM, Strand JJ, Wordingham SE, Stulak JM, Luckhardt AJ, Swetz KM. Dying With a Left Ventricular Assist Device as Destination Therapy. Circ Heart Fail 2017; 9:CIRCHEARTFAILURE.116.003096. [PMID: 27758809 DOI: 10.1161/circheartfailure.116.003096] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 09/02/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the ability of left ventricular assist device as destination therapy (DT-LVAD) to prolong survival for many patients with advanced heart failure, little is known about the eventual end-of-life care that patients with DT-LVAD receive. METHODS AND RESULTS All patients undergoing DT-LVAD at the Mayo Clinic in Rochester, Minnesota, from January 1, 2007, to September 30, 2014, who subsequently died before July 1, 2015, were included. Information about end-of-life care was obtained from documentation in the electronic medical record. Of 89 patients who died with a DT-LVAD, the median (25th-75th percentile) time from left ventricular assist device implantation to death was 14 (4-31) months. The most common causes of death were multiorgan failure (26%), hemorrhagic stroke (24%), and progressive heart failure (21%). Nearly half (46%) of the patients saw palliative care within 1 month before death; however, only 13 (15%) patients enrolled in hospice a median 11 (range 1-315) days before death. Most patients (78%) died in the hospital, of which 88% died in the intensive care unit. In total, 49 patients had their left ventricular assist device deactivated before death, with all but 3 undergoing deactivation in the hospital. Most patients died within an hour of left ventricular assist device deactivation and all within 26 hours. CONCLUSIONS In contrast to the general heart failure population, most patients with DT-LVAD die in the hospital and few use hospice. Further work is needed to understand these differences and to determine whether patients with DT-LVAD are receiving optimal end-of-life care.
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Affiliation(s)
- Shannon M Dunlay
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.).
| | - Jacob J Strand
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - Sara E Wordingham
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - John M Stulak
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - Angela J Luckhardt
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
| | - Keith M Swetz
- From the Department of Cardiovascular Diseases (S.M.D.), the Division of Health Care Policy and Research, Department of Health Sciences Research (S.M.D.), the Division of General Internal Medicine, Department of Medicine (J.J.S.), and the Division of Cardiovascular Surgery, Department of Surgery (J.M.S., A.J.L.), Mayo Clinic, Rochester, MN; Division of Hematology & Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, AZ (S.E.W.); and Department of Medicine and Center for Palliative & Supportive Care, University of Alabama Birmingham, and the Birmingham Veterans Affairs Medical Center, AL (K.M.S.)
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Adlbrecht C, Hülsmann M, Wurm R, Eskandary F, Neuhold S, Zuckermann A, Bojic A, Strunk G, Pacher R. Outcome of conservative management vs. assist device implantation in patients with advanced refractory heart failure. Eur J Clin Invest 2016; 46:34-41. [PMID: 26540663 DOI: 10.1111/eci.12562] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 10/29/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND In patients with advanced refractory heart failure (HF) cardiac transplantation (HTX), conservative medical management and the implantation of a ventricular assist device (VAD) represent valuable options. The determination of the best therapeutic destination strategy for the individual patient remains a challenge. The aim of this study was to assess the clinical outcome in advanced refractory HF patients either managed conservatively receiving optimal contemporary medical therapy ('conservative'), or who who underwent pulsatile flow VAD ('pVAD') or continuous-flow VAD ('contVAD') implantation. MATERIALS AND METHODS A total of 118 patients with INTERMACS profile >1 at baseline, who died, or fully completed a 24-month follow-up free from HTX were included into this retrospective analysis. All-cause mortality at 24 months was assessed and compared between the three groups. RESULTS Fifty (42%) patients were managed conservatively, 25 (21%) received a pVAD and 43 (36%) a contVAD. NT-proBNP values were comparable between the three groups (median 4402 (IQR 2730-13390) pg/mL, 3580 (1602-6312) pg/mL and 3693 (2679-8065) pg/mL, P = 0·256). Mean survival was 18·6 (95% CI 16·2-21·0) months for patients managed conservatively, 7·0 (3·9-10·0) for pVAD and 20·5 (18·2-22·8) for contVAD (overall log-rank test P < 0·001). Conservatively managed patients spent a mean of 22·4 (95% CI 22·1-22·8), pVAD 17·7 (15·4-20·1) and contVAD 21·6 (21·2-22·1) months out of hospital (conservative vs. pVAD P < 0·001; conservative vs. contVAD P = 0·015; pVAD vs. contVAD P < 0·001). CONCLUSIONS In accordance with the literature, contVAD resulted in a significantly better clinical outcome than pVAD implantation. However, conservative management with current optimal medical therapy appears to remain a valuable option for patients with advanced HF.
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Affiliation(s)
- Christopher Adlbrecht
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria.,4th Medical Department, Hietzing Hospital, Medical University of Vienna, Vienna, Austria
| | - Martin Hülsmann
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Raphael Wurm
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Farsad Eskandary
- Division of Nephrology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Stephanie Neuhold
- Division of Cardio-Thoracic-Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Medical University of Vienna, Vienna, Austria.,Division of Infectiology and Tropical Medicine, Department of Internal Medicine IV, KFJ Social-Medical Center South, Medical University of Vienna, Vienna, Austria
| | - Andreas Zuckermann
- Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Andja Bojic
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Guido Strunk
- Complexity-Research, Research Institute for Complex Systems, Vienna, Austria
| | - Richard Pacher
- Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
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