HFSA/SAEM/ISHLT Clinical Expert Consensus Document on the Emergency Management of Patients with Ventricular Assist Devices

Left Ventricular Assist Device: Review of Antimicrobial Prophylaxis Strategies and Incidence of Infections at a Tertiary Care Center 12-Year Experience

Background

Left ventricular assist devices (LVAD) have an associated infection rate of 13%-80% postimplant. An optimal strategy for surgical infection prophylaxis (SIP) at the time of implantation has not been well defined. We aimed to evaluate the different LVAD implantation antibiotic prophylaxis regimens as well as the incidence of LVAD infection at our institution.

Methods

We performed a single-center, retrospective study of patients who underwent LVAD implantation between February 2007 and June 2019. The primary outcome was the incidence of LVAD infection (LVADI), within 3 months and 1 year of placement, between patients who received expanded or narrow-spectrum regimens for SIP. We assessed outcomes using Kaplan-Meier, time-to-first event. We used a noninferiority analysis, which was established if the narrow-spectrum event rate was no more than 5% greater than the expanded-spectrum event rate.

Results

We included 399 patients, 305 (76.4%) patients received narrow-spectrum SIP, whereas the remaining 94 (23.6%) patients received the expanded-spectrum regimen. Statistical noninferiority of the narrow spectrum to the multiple drug regimen was demonstrated at both time points, and statistical superiority of the narrow-spectrum group across 12-month follow up was further evident (P = .037).

Conclusions

We report evidence supporting noninferiority, or even superiority, of the narrow-spectrum over expanded-spectrum antimicrobial prophylaxis strategy with respect to LVADI. These findings support data-driven antimicrobial prophylaxis strategies.

Left Ventricular Assist Devices: A Primer for the Non-Mechanical Circulatory Support Provider

Survival after implant of a left ventricular assist device (LVAD) continues to improve for patients with end-stage heart failure. Meanwhile, more patients are implanted with a destination therapy, rather than bridge-to-transplant, indication, meaning the population of patients living long-term on LVADs will continue to grow. Non-LVAD healthcare providers will encounter such patients in their scope of practice, and familiarity and comfort with the physiology and operation of these devices and common problems is essential. This review article describes the history, development, and operation of the modern LVAD. Common LVAD-related complications such as bleeding, infection, stroke, and right heart failure are reviewed and an approach to the patient with an LVAD is suggested. Nominal operating parameters and device response to various physiologic conditions, including hypo- and hypervolemia, hypertension, and device failure, are reviewed.

Novel Risk Model to Predict Emergency Department Associated Mortality for Patients Supported With a Ventricular Assist Device: The Emergency Department-Ventricular Assist Device Risk Score

Background The past decade has seen tremendous growth in patients with ambulatory ventricular assist devices. We sought to identify patients that present to the emergency department (ED) at the highest risk of death. Methods and Results This retrospective analysis of ED encounters from the Nationwide Emergency Department Sample includes 2010 to 2017. Using a random sampling of patient encounters, 80% were assigned to development and 20% to validation cohorts. A risk model was derived from independent predictors of mortality. Each patient encounter was assigned to 1 of 3 groups based on risk score. A total of 44 042 ED ventricular assist device patient encounters were included. The majority of patients were male (73.6%), <65 years old (60.1%), and 29% presented with bleeding, stroke, or device complication. Independent predictors of mortality during the ED visit or subsequent admission included age ≥65 years (odds ratio [OR], 1.8; 95% CI, 1.3-4.6), primary diagnoses (stroke [OR, 19.4; 95% CI, 13.1-28.8], device complication [OR, 10.1; 95% CI, 6.5-16.7], cardiac [OR, 4.0; 95% CI, 2.7-6.1], infection [OR, 5.8; 95% CI, 3.5-8.9]), and blood transfusion (OR, 2.6; 95% CI, 1.8-4.0), whereas history of hypertension was protective (OR, 0.69; 95% CI, 0.5-0.9). The risk score predicted mortality areas under the curve of 0.78 and 0.71 for development and validation. Encounters in the highest risk score strata had a 16-fold higher mortality compared with the lowest risk group (15.8% versus 1.0%). Conclusions We present a novel risk score and its validation for predicting mortality of patients with ED ventricular assist devices, a high-risk, and growing, population.

VAD 911: Process Improvement for First Responders Treating Ventricular Assist Device Patients

Ventricular assist devices (VAD) complications including stroke, device failure, gastrointestinal bleeding, and infection all can manifest in the outpatient environment. Often, first responders do not have the knowledge base to respond appropriately. This study conducted an assessment of first responders generalized knowledge and self-reported competency regarding VAD use, provided an education course, and tested for improvement immediately after and 1 month postintervention. Two hundred thirty-six first responders participated from communities with known VAD patients. Responses indicated poor knowledge, experience, and competency. Twenty-one percent had seen a manufacturer training video, 26% had attended prior training, and 38% knew who to contact with a VAD emergency. Generalized knowledge of VAD therapy was poor with majority not understanding use of anticoagulation, when to initiate chest compressions and assessment variations. Self-reported competency was low with 80% of participants reporting unsafe to marginal about VAD awareness. Comparison of 1 month postintervention to preintervention, generalized knowledge improved by a minimum of 38% for each question and competency increased by over 50%. From this study comes the recommendation that VAD centers must include the community first responders as part of their discharge planning for the VAD patient and improve community outreach to ensure appropriate patient outcomes.

An Emergency Medicine-focused Summary of the HFSA/SAEM/ISHLT Clinical Consensus Document on the Emergency Management of Patients With Ventricular Assist Devices

Mechanical circulatory support is increasingly used as a long-term treatment option for patients with end-stage heart failure. Patients with implanted ventricular assist devices are at high risk for a range of diverse medical urgencies and emergencies. Given the increasing prevalence of mechanical circulatory support devices, this expert clinical consensus document seeks to help inform emergency medicine and prehospital providers regarding the approach to acute medical and surgical conditions encountered in these complex patients.

Effect of a New Cardiac Massage Facilitator Device on the Fatigue of Rescue Workers in Cardiopulmonary Resuscitation

Introduction: Cardiopulmonary resuscitation is a direct intervention for the prevention or postponement of death in patients with cardiac arrest. The fatigue of rescue workers is of high significance when performing cardiopulmonary resuscitation effectively. The present study aimed to investigate the effect of a cardiac massage facilitator device on the fatigue of rescue workers in cardiopulmonary resuscitation.

Materials and Methods: This experimental study was carried out on 30 emergency medical aid non-continuous bachelor students, divided equally into two groups: one group performed cardiac massage using the device and the other without the device. Fatigue levels were assessed using a visual analog scale to evaluate fatigue severity.

Results: The mean age of participants was 23.42 ± 2.02 years, the mean height was 175 ± 4.43 cm, and the mean weight was 65.45 ± 5.02 kg. There was a statistically significant difference between the mean fatigue scores of the two groups: 0.06 with the device vs. 0.57 without the device.

Conclusion: Our results suggest that the cardiac massage facilitator device presented in this study could be effective in improving the quality of cardiac massage and be helpful in cardiopulmonary resuscitation.