Nutrition Assessment and Management of Left Ventricular Assist Device Patients

Association between malnutrition risk and the prognosis of geriatric heart failure patients undergoing left ventricular assist device implantation

BACKGROUND

Evidence regarding the association between malnutrition risk and the prognosis of geriatric heart failure (HF) patients undergoing left ventricular assist device (LVAD) implantation is lacking. Our study aims to investigate how malnutrition risk, assessed using the geriatric nutritional risk index (GNRI) values, relates to the outcomes of geriatric HF patients undergoing LVAD, using data from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry.

METHODS

A retrospective analysis was conducted using data from INTERMACS registry. Patients aged 65 and above who received LVAD implantation between 2008 and 2017 were included. The GNRI was used to stratify patients into three groups: absence of risk (GNRI > 98), mild risk (GNRI 92-98), and moderate to severe risk (GNRI < 92). The primary outcome was long-term survival for up to four years following LVAD implantation.

RESULTS

We included 5429 patients aged 65 and above undergoing LVADs. The malnutrition risk was presented in 75.8% of the patients before implantation, decreasing to 32.4% at 3 months, and 59.5% at 24 months post-implantation. Moderate-to-severe malnutrition risk, both pre-implant and 6 months post-implant, was associated with an increased risk of death (pre-implant: hazard ratio (HR): 1.25 [95% CI: 1.12-1.40], p < 0.001; 6 months: HR: 2.36 [95% CI: 2.01-2.77], p < 0.001). Mortality decreased with increasing pre-implant GNRI up to approximately 100 and 6-month post-implant GNRI up to 104. Patients with malnutrition risk also had an increased risk of infection, poor quality of life (QoL), and reduced functional exercise capacity after the LVAD implantation.

CONCLUSIONS

Malnutrition risk was highly prevalent in HF patients aged 65 and above undergoing LVADs implantation. The presence of malnutrition risk was associated with an increased risk of death, infection, poor quality of life, and reduced functional exercise capacity.

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

Cellular and Molecular Mechanisms Activated by a Left Ventricular Assist Device

Left ventricular assist devices (LVADs) represent the final treatment for patients with end-stage heart failure (HF) not eligible for transplantation. Although LVAD design has been further improved in the last decade, their use is associated with different complications. Specifically, inflammation, fibrosis, bleeding events, right ventricular failure, and aortic valve regurgitation may occur. In addition, reverse remodeling is associated with substantial cellular and molecular changes of the failing myocardium during LVAD support with positive effects on patients' health. All these processes also lead to the identification of biomarkers identifying LVAD patients as having an augmented risk of developing associated adverse events, thus highlighting the possibility of identifying new therapeutic targets. Additionally, it has been reported that LVAD complications could cause or exacerbate a state of malnutrition, suggesting that, with an adjustment in nutrition, the general health of these patients could be improved.

Supplemental nutrition, feeding disorders, and renourishment in pediatric heart failure through transplantation

BACKGROUND

Tube feeds are used commonly in children listed for heart transplant; however, rates of renourishment and development of feeding disorders are not sufficiently characterized.

METHODS

Retrospective review of pediatric heart transplant recipients from January 1, 2014, to January 3, 2021. Demographics, anthropometric, and nutritional data were collected from heart transplant listing through 3 years post-transplant. Renourishment rates, presence of a feeding disorder, and need for a gastric feeding tube were analyzed. Multivariable analysis was conducted to identify risks for poor nutritional outcomes.

RESULTS

Of 104 patients, 35 (34%) and 36 (35%) were malnourished at heart transplant listing and transplant, respectively, persisting in 21/91 (23%) 1 year postheart transplant. Forty (38%) received tube feeds at listing, 42 (40%) at heart transplant, and 18/90 (20%) 1 year post-transplant. Rates of feeding disorders fell from 23% at transplantation to 10% 1 year post-transplant. Feeding disorders were associated with younger age at heart transplant (p < .001) and congenital heart disease (p = .03). Forty-six percent of infants required a gastric feeding tube. Renourishment occurred in 20% during listing and was associated with ventricular assist device support (p = .03) and noncalorically dense feeds (p = .03). Malnutrition at transplant was associated with inferior post-transplant survival (6/36 (17%) vs. 2/68 (3%); p = .02).

CONCLUSIONS

Malnourishment requiring tube feeds is common in pediatric heart transplant candidates; however, most patients who eventually survive to transplant remain malnourished at time of transplantation and 1 year later. While some children develop feeding disorders, they generally resolve by 1 year post-transplant.

Controlling Nutritional Status Score As a Predictive Marker for Patients With Implantable Left Ventricular Assist Device

Although a correlation between the nutritional status and the prognosis of patients with heart failure has been suggested, a correlation between the nutritional status and outcomes after the left ventricular assist device (LVAD) implantation remains unclear. We aimed to investigate the efficacy of the Controlling Nutritional Status (CONUT) score (range 0-12, including serum albumin, total cholesterol, and lymphocytes) as a nutritional index in speculating the prognosis of patients undergoing LVAD implantation. We examined 63 consecutive patients who underwent the continuous-flow LVAD implantation. Using the preoperative CONUT score, patients were categorized into two groups: lower CONUT score (0-4: normal to mild malnutrition) and higher CONUT score (5-12: moderate to severe malnutrition). We compared for the backgrounds and the clinical events after LVAD implantation. The higher CONUT group exhibited a significantly higher mean right atrial pressure (10.9 ± 4.7 vs. 7.3 ± 4.1 mmHg; p = 0.0019). In that group, the mortality rate was significantly higher (25% vs. 2.6%; p = 0.0059) and the Kaplan-Meier analysis showed lower survival rate. Furthermore, more bleeding events significantly occurred in the higher CONUT group. The preoperative CONUT score may reflect systemic venous congestion and offer a useful prognostic index of clinical courses after LVAD implantation.

Preoperative prealbumin does not impact outcomes after left ventricular assist device implantation

BACKGROUND

This single-center, the retrospective study evaluates the impact of preoperative serum prealbumin levels on outcomes after left ventricular assist device (LVAD) implantation.

METHODS

Adults undergoing LVAD implantation, with a recorded preoperative prealbumin level, between 2004 to 2018 were included. Primary outcomes included rates of 1-year survival and secondary outcomes included rates of postimplant adverse events. Threshold regression and restricted cubic splines were utilized to identify a cut-point to dichotomize prealbumin level. Prealbumin was also evaluated as a continuous variable. Multivariable logistic regression was used for risk-adjustment.

RESULTS

A total of 333 patients were included. Patients were dichotomized according to an optimal prealbumin threshold of 15 mg/dL: 47.4% (n = 158) had levels below and 52.6% (n = 175) had levels above this threshold, respectively. The rates of postimplant adverse events, including bleeding, infection, stroke, renal failure, and right heart failure, were similar between the groups (all P > .05). Furthermore, the rates of cardiac transplantation and device explantation were also similar (all P > .05). Unadjusted survival was comparable between the groups at 30-days, 90-days, and 1-year following LVAD implantation (all P > .05). In addition, lower prealbumin did not impact risk-adjusted 1-year mortality when modeled either as a categorical (OR, 1.08; 95% CI, 0.48-2.12; P = .82) or continuous variable (OR, 1.99; 95% CI, 0.73-2.34; P = .96).

CONCLUSIONS

This study demonstrates that lower prealbumin levels were not predictive of increased post-LVAD morbidity or mortality. Although an established marker of nutritional and inflammatory status, the role of prealbumin in patient selection or prognostication appears limited in LVAD patients.

2019 EACTS Expert Consensus on long-term mechanical circulatory support

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

Relationship Between SCUBE1 Levels and Echocardiography and Electrocardiography Findings and Epicardial Adipose Tissue/Carotid Intima-Media Thickness in Patients Receiving Renal Replacement Therapy

OBJECTIVES

In patients with advanced-stage chronic kidney disease, renal insufficiency, arterial stiffness, and vascular calcification are strong predictors of cardiovascular risk. Signal peptide-CUB-EGF-like protein-1 (SCUBE1) levels increase during platelet activation and acute ischemic events. Here, we evaluated associations between SCUBE1 levels and electrocardiographic/echocardiographic findings, epicardial adipose tissue thickness, and carotid intimamedia thickness in patients with chronic kidney disease.

MATERIALS AND METHODS

Our study included 21 renal transplant recipients, 20 peritoneal dialysis patients, 20 hemodialysis patients, 20 predialysis patients with glomerular filtration rate < 30 mL/min, and 16 healthy volunteers.

RESULTS

We found no differences in SCUBE1 levels between patient groups and healthy volunteers, regardless of history of diabetes mellitus, myocardial infarction, cerebrovascular events, and hypertension. SCUBE1 levels correlated with C-reactive protein in renal transplant recipients; magnesium in peritoneal dialysis patients; erythrocyte sedimentation rate in predialysis patients; and parathyroid hormone, platelet count, calcium-phosphate product, and calcium in hemo dialysis patients. No associations were shown between SCUBE1 levels and electrocardiographic/echocardiographic findings. Elevated C-reactive protein in predialysis patients was associated with cardiac valvular pathologies. In hemodialysis patients, SCUBE1 levels increased after hemodialysis (P = .007). Levels were higher in healthy individuals with normal echocardiography and predialysis patients with left ventricular diastolic dysfunction. Positive correlations were found between carotid intima-media thickness and SCUBE1 levels in dialysis patients (P < .05), but no study groups showed correlations regarding epicardial adipose tissue thickness.

CONCLUSIONS

Hemodialysis may contribute to cardiovascular events because of increased SCUBE1 levels after hemodialysis; however, no association was shown between SCUBE1 and electrocardiography/echocardiography findings. We found no correlations between epicardial adipose tissue thickness and SCUBE1 levels, and levels were significantly higher in healthy patients and in predialysis patients without left ventricular diastolic dysfunction. However, correlations were shown between SCUBE1 levels and carotid intima-media thickness and secondary hyperparathyroidism markers, indicating associations with atherosclerosis and bone mineral disease in dialysis patients.

Different Clinical Course and Complications in Interagency Registry for Mechanically Assisted Circulatory Support 1 (INTERMACS) Patients Managed With or Without Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) as a bridge to left ventricular assist device (LVAD) implantation has shown promise in improving end-organ function and optimizing outcomes in some critically ill patients, but the practice remains controversial. Retrospective review of patients who received LVADs from May 2008 to September 2016 at a high-volume, tertiary care cardiovascular center was performed. Subjects were Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) class 1 patients divided into ECMO bridge and non-ECMO bridge cohorts. Patient demographics, adverse events, and survival at immediate and 1 year postoperative time points were compared between groups. In total, 235 patients received a HeartMate II or HVAD during the study period. Among INTERMACS 1 patients, 18 were ECMO bridge and 17 were non-ECMO bridge. Age, gender and bridge-to-transplant proportions (50% vs. 53%) were similar between groups. The ECMO bridge group had lower hemoglobin (7.9 ± 1.1 vs. 10.2 ± 2.2; p < 0.01), platelet (101 [70] vs. 176 [115]; p < 0.05), and prealbumin levels (10.6 ± 4.3 vs. 17.3 ± 7.7; p < 0.01). Nearly half (n = 8; 44%) of the ECMO bridge patients required packed red blood cell transfusions before VAD and were more likely to be on an epinephrine drip (78% vs. 12%; p < 0.01). However, along with these adjunctive measures, the ECMO bridge did effectively improve hemodynamic profiles by the time of VAD implant resulting in lower central venous pressure (7.7 ± 2.5 vs. 10.4 ± 4.8; p < 0.01) and mean pulmonary arterial pressure (18 ± 9 vs. 32 ± 8; p < 0.01). It also allowed for restoration of end-organ function as noted by comparable creatinine (1.0 [1.2] vs. 1.4 [0.6]) and total bilirubin levels (1.6 ± 1 vs.1.5 ± 1.7) between the two groups. There was no difference in rates of adverse events. Survival at 30 days postoperative and at 1 year (77% vs. 88%; p = 0.6) was similar. This study demonstrates that ECMO bridge is a central component of a multifaceted strategy for stabilization of select patients with severe hemodynamic instability before LVAD implantation. Further studies to optimize patient selection should be further explored.

Impact of ventricular assist device implantation on the nutritional status of children awaiting heart transplantation

BACKGROUND

Malnutrition is common in pediatric heart failure and is associated with mortality. The effect of VAD support on malnutrition in children is unknown. We sought to compare the prevalence and severity of malnutrition at HT in children on VAD support vs OMT to inform decisions regarding support strategies.

METHODS

Retrospective chart review involving all patients <18 years who underwent HT at Stanford between 1/1/2011 and 3/1/2018. Malnutrition diagnosis and severity were defined by ASPEN guidelines using the lowest age-adjusted z-score for weight (WAZ), height (HAZ), and BMI (BMIZ) when the patient was euvolemic. Changes in z-scores from baseline to HT and across groups were analyzed.

RESULTS

A total of 104 patients (52 in each group) were included. Among all patients, WAZ (-0.9 vs 0.3, P < 0.001) and BMIZ (0 vs 0.6, P < 0.001) improved while HAZ (-0.9 vs -0.9, P = 0.4) did not. Compared to children on OMT, children on VAD experienced greater increases in WAZ (0.8 vs 0.3, P < 0.001) and BMIZ (0.7 vs 0.2, P < 0.003) at HT. The prevalence of moderate-to-severe malnutrition decreased in VAD patients (40% to 19%, P < 0.001) and increased in OMT patients (37% to 46%, P < 0.001), leading to a lower prevalence of moderate-to-severe malnutrition at HT (19% vs 46%, P = 0.003).

CONCLUSIONS

Malnutrition is common in pediatric HT candidates. Compared to children on OMT, children on VAD support had greater improvement in nutritional status while awaiting HT, and a lower prevalence of malnutrition at HT.

Risk of left ventricular assist device driveline infection: A systematic literature review

BACKGROUND

Left ventricular assist devices (LVADs) improve quality of life in end-stage heart failure but can cause serious complications such as infections with driveline infection causing significant morbidity and mortality.

OBJECTIVES

The purpose of this systematic literature review is to synthesize the literature to determine variables associated with driveline infection and seek opportunities to improve nursing management of LVAD drivelines.

METHODS

A systematic literature review was performed. The evidence was synthesized using the Johns Hopkins Nursing Evidence-Based Practice tools and the Chain of Infection epidemiological framework.

RESULTS

Thirty-four studies focused on vulnerable host, portal of entry, and causative organism aspects of the Chain of Infection. Increased BMI, younger age, exposed driveline velour showed increased risk of infection and driveline dressing protocol change showed lower risk of infection.

CONCLUSIONS

Although some risk factors for infection were identified, evidence is still limited. Nurses are uniquely positioned to improve driveline management, disrupting the chain of infection.

Prognostic Value of the Nutritional Risk Index in Candidates for Continuous Flow Left Ventricular Assist Device Therapy

INTRODUCTION AND OBJECTIVES

Malnutrition has been shown to affect clinical outcomes in patients with heart failure. The aim of this study was to analyze the impact of preoperative nutritional status assessed by the nutritional risk index (NRI) on the prognosis of patients with a continuous-flow left ventricular assist device (cf-LVAD).

METHODS

We performed a retrospective study of 279 patients who underwent cf-LVAD implantation between 2009 and 2015 in our center. Preoperative NRI was calculated and the patients were followed-up for 1 year. The association between preoperative NRI and postoperative clinical events was analyzed using multivariable logistic regression.

RESULTS

The prevalence of severe (NRI <83.5), moderate (83.5 ≤ NRI <97.5) and mild (97.5 ≤ NRI <100) nutritional risk was 5.4%, 21.5%, and 9.3%. Mortality rates 1 year after cf-LVAD implantation in these 3 categories were 53.3%, 31.7%, 23.1% vs 18.0% (P <.001) in patients with a normal IRN. A normal preoperative NRI value was an independent predictor of lower risk of death from any cause during follow-up (aHR per 1 unit, 0.961; 95%CI, 0.941-0.981; P <.001) was and a predictor for a lower risk of postoperative infections (aOR, 0.968; 95%CI, 0.946-0.991; P=.007), respiratory failure (aOR, 0,961; 95%CI, 0.936-0.987; P=.004), and right heart failure (aOR, 0.963; 95%CI, 0.934-0.992; P=.014).

CONCLUSIONS

Malnourished patients are at increased risk for postoperative complications and death after cf-LVAD implantation. Assessment of nutritional risk could improve patient selection and the early initiation of nutritional support.

Successful Placement of Nasointestinal Feeding Tubes Using an Electromagnetic Sensor-Guided Enteral Access System in Patients With Left Ventricular Assist Devices

Technology advances have made it possible to prolong life for patients with heart failure who are not transplant candidates or while awaiting transplant. Many different cardiac devices are available that can be used as a bridge to transplant (temporary support) or as a destination therapy (permanent support). Placement of these devices can cause complications that, if not addressed, could negatively impact the nutrition status of patients. Placement of nasointestinal feeding tubes using an electromagnetic sensor-guided enteral access system (EMS-EAS) has been difficult in patients with implantable devices because of the potential for interference with the EMS-EAS and the left ventricular assist device (LVAD). The purpose of this paper was to report the results using a modified method to place nasointestinal tubes in patients with LVADs by elevating the receiver off the xiphoid process. There were 42 feeding tube placements in 25 patients. Results showed a 69% success rate of placement into the small bowel, 13 unsuccessful placements, and no adverse or sentinel events associated with tube placement using this method. Results indicated the modified method is a safe approach to help expedite feeding tube placement in a nutritionally compromised patient. The success rate is comparable with non-LVAD patient populations requiring nasointestinal tube placement via EMS-EAS. To our knowledge, this is the first published case series addressing a modified method for nasointestinal tube placement in patients with LVAD. More research is needed to determine ideal separation distances or other techniques to improve the success rate in this patient population.

Left Ventricular Assist Device in Older Adults

Left ventricular assist devices (LVADs) are an effective therapy for a growing and aging population in the background of limited donor supply. Selecting the proper patient involves assessment of indications, risk factors, scores for overall outcomes, assessment for right ventricular failure, and optimal timing of implantation. LVAD complications have a 5% to 10% perioperative mortality and complications of bleeding, thrombosis, stroke, infection, right ventricular failure, and device failure. As LVAD engineering technology evolves, so will the risk-prediction scores. Hence, more large-scale prospective data from multicenters will continually be required to aid in patient selection, reduce complications, and improve long-term outcomes.

Current Status of Left Ventricular Assist Device Therapy

Congestive heart failure (HF) remains a serious burden in the Western World. Despite advances in pharmacotherapy and resynchronization, many patients have progression to end-stage HF. These patients may be candidates for heart transplant or left ventricular assist device (LVAD) therapy. Heart transplants are limited by organ shortages and in some cases by patient comorbidities; therefore, LVAD therapy is emerging as a strategy of bridge to transplant or as a destination therapy in patients ineligible for transplant. Patients initially ineligible for a transplant may, in certain cases, become eligible for transplant after physiologic improvement with LVAD therapy, and a small number of patients with an LVAD may have sufficient recovery of myocardial function to allow device explantation. This clinically oriented review will describe (1) the most frequently used pump types and aspects of the continuous-flow physiology and (2) the clinical indications for and the shift toward the use of LVADs in less sick patients with HF. Additionally, we review complications of LVAD therapy and project future directions in this field. We referred to the Interagency Registry for Mechanically Assisted Circulatory Support, landmark trials, and results from recently published studies as major sources in obtaining recent outcomes, and we searched for related published literature via PubMed. This review focuses primarily on clinical practice for primary care physicians and non-HF cardiologists in the United States.

Safety of percutaneous endoscopic gastrostomy tube placement in patients with continuous-flow ventricular assist devices

In this retrospective study, the safety of percutaneous endoscopic gastrostomy (PEG) tube placement was evaluated as maintaining adequate nutritional support for patients with left ventricular assist devices is crucial. Nineteen patients who underwent PEG tube placement were followed for an average of 40 days. Overall, minor complications such as infections, bleeding, and PEG tube malposition occurred in just 19% of patients while the rate of major complications such as perforation was 5%. Further randomized control trials are necessary to validate this assertion that the safety of PEG placement in patients with left ventricular assist devices is similar to that of the general population.

A simple education tool for ventricular assist device patients and their caregivers

BACKGROUND

Ventricular assist devices (VADs) have become an important therapy in the management of patients with end-stage heart failure. Driveline infection is the most common late-onset complication in this group of patients. Patients and their caregivers require education regarding management of the driveline to reduce the risk of infection when they are discharged home with a VAD.

PURPOSE

The aim of this study was to develop an educational booklet on VAD driveline care for patients and their caregivers. A literature review was undertaken to explore the availability of patient education material pertaining to driveline management and to update evidence-informed knowledge that could potentially reduce infection rates in these patients. This information was evaluated by peers, patients, and caregivers to produce the final colored booklet.

CONCLUSIONS

Driveline care is not comprehensively discussed in the literature and lacks detail in the particulars of wound care, patient education, and the adaptation of driveline care to the patient's home environment. An educational booklet was designed to convey what is currently known about preventing driveline infections to those who are responsible for providing the required daily care. Evaluation of patient education material by those using the material is essential. As with all written material, the information will require updating as new evidence becomes available.

CLINICAL IMPLICATIONS

Managing driveline infection risk for patients at home with extended therapy is a critical nursing issue in improving morbidity and mortality. After VAD implantation, patients and caregivers must be educated about the ongoing care of the driveline exit site to minimize the risk of infection. A rigorously developed and patient-evaluated educational booklet on driveline exit site care can be a valuable reference tool for patients and caregivers after hospital discharge.

Perioperative Hypoalbuminemia Affects Improvement in Exercise Tolerance After Left Ventricular Assist Device Implantation

BACKGROUND

Although survival rates have improved for patients receiving implantable continuous flow left ventricular assist devices (I-CF LVAD), postoperative exercise tolerance levels are not necessarily satisfactory.

METHODS AND RESULTS

We enrolled 51 patients who had received an I-CF LVAD and underwent follow-up between 2006 and 2014; all patients underwent cardiopulmonary exercise testing 3 months following surgery: 26 (51%) patients achieved peak oxygen consumption (PV̇O2) ≥14 ml·kg(-1)·min(-1)and had significantly lower readmission rates for cardiovascular events than those with PV̇O2<14 ml·kg(-1)·min(-1)during 2 years of LVAD treatment (17 vs. 43%, P=0.033). Uni- and multivariate logistic regression analyses showed that the preoperative serum albumin (S-ALB) level was an independent predictor for PV̇O2≥14 ml·kg(-1)·min(-1)at 3 months (P=0.023, odds ratio 6.132). Patients with persistently normal S-ALB levels during the perioperative period had the lowest preoperative serum C-reactive protein level (S-CRP, 0.7±0.9 mg/dl), and the majority (77%) showed improved exercise tolerance. Conversely, patients with persistently low S-ALB levels during this period had the highest preoperative S-CRP level (2.8±1.2 mg/dl) and did not achieve the test endpoint.

CONCLUSIONS

Both pre- and postoperative low S-ALB impedes recovery of exercise tolerance after I-CF LVAD surgery, and this may be attributable to inflammatory responses caused by heart failure.

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.

Dynamics of device innovation: implications for assessing value

BACKGROUND

In recent years, there has been growing interest in evaluating the health and economic impact of medical devices. Payers increasingly rely on cost-effectiveness analyses in making their coverage decisions, and are adopting value-based purchasing initiatives. These analytic approaches, however, have been shaped heavily by their use in the pharmaceutical realm, and are ill-adapted to the medical device context.

METHODS

This study focuses on the development and evaluation of left ventricular assist devices (LVADs) to highlight the unique challenges involved in the design and conduct of device trials compared with pharmaceuticals.

RESULTS

Devices are moving targets characterized by a much higher degree of post-introduction innovation and "learning by using" than pharmaceuticals. The cost effectiveness ratio of left ventricular assist devices for destination therapy, for example, decreased from around $600,000 per life year saved based on results from the pivotal trial to around $100,000 within a relatively short time period.

CONCLUSIONS

These dynamics pose fundamental challenges to the evaluation enterprise as well as the policy-making world, which this paper addresses.

Malnutrition and Cachexia in Heart Failure

Heart failure is a growing public health concern. Advanced heart failure is frequently associated with severe muscle wasting, termed cardiac cachexia This process is driven by systemic inflammation and tumor necrosis factor in a manner common to other forms of disease-related wasting seen with cancer or human immunodeficiency virus. A variable degree of malnutrition is often superimposed from poor nutrient intake. Cardiac cachexia significantly decreases quality of life and survival in patients with heart failure. This review outlines the evaluation of nutrition status in heart failure, explores the pathophysiology of cardiac cachexia, and discusses therapeutic interventions targeting wasting in these patients.

Readmission due to driveline infection can be predicted by new score by using serum albumin and body mass index during long-term left ventricular assist device support

Survival in patients with continuous flow left ventricular assist device (CF LVAD) had been increased owing to improved perioperative management procedures. The second target for successful long-term LVAD treatment was to reduce readmission especially due to device-specific infection, which was one of the major unsolved complications. Among 57 enrolled patients who had received CF LVAD and been followed for 530 days on median at our institute between 2008 and 2014, 21 patients experienced readmission due to driveline infection (DLI) at 190 days after the surgery on median. Considering the result of Uni/Multivariate Cox regression analyses demonstrating lower serum albumin concentration (S-ALB) (hazard ratio 0.144) and body mass index (BMI) (hazard ratio 0.843) both obtained at discharge were independent predictors of readmission due to DLI, we constructed a New Score "7 × [S-ALB (g/dL)] + [BMI]", which significantly stratified readmission-free rate into 3 groups [low (>50 Pt), intermediate (44-50 Pt), and high risk group (<44 Pt)] during 2-year study period (p = 0.008). Survival remained unchanged irrespective of DLI, whereas those with DLI needed longer in-hospital treatment (p < 0.05). In conclusion, readmission due to DLI could be predicted by using two simple nutrition parameters at discharge. Early nutrition assessment and intervention may reduce readmission and improve patients' quality of life during long-term LVAD support.

Ventricular-assist devices for the treatment of chronic heart failure

The role of ventricular-assist devices in the management of end-stage heart failure is growing. Initially developed as a 'bridge to transplantation', they are now implanted permanently in patients who need cardiac replacement but are not candidates for cardiac transplantation ('destination therapy'). Furthermore, observations from expert centers indicate that a significant proportion of patients under long-term mechanical assistance can be weaned from mechanical circulatory support after significant functional recovery of their native heart ('bridge to recovery'). This review discusses the emerging roles of mechanical circulatory support and their direct implications in clinical practice. Evolution of devices, important aspects of candidate selection, challenging issues in the management of ventricular-assist device patients (infection, device malfunction, anticoagulation-thromboembolic complications, psychosocial issues and cost) and ongoing research targeting sustained myocardial recovery are discussed.

Advances and future directions for mechanical circulatory support

Although cardiac transplant remains the gold standard for the treatment of end-stage heart failure, limited donor organ availability and growing numbers of eligible recipients have increased the demand for alternative therapies. Limitations of first-generation left ventricular assist devices for long-term support of patients with end-stage disease have led to the development of newer second-generation and third-generation pumps, which are smaller, have fewer moving parts, and have shown improved durability, allowing for extended support. The HeartMate II (second generation) and HeartWare (third generation) are 2 devices that have shown great promise as potential alternatives to transplantation in select patients.

Variability in infection control measures for the percutaneous lead among programs implanting long-term ventricular assist devices in the United States

Ventricular assist devices (VADs) are a surgical treatment for heart failure. These devices may be implanted as a bridge to transplant or as destination therapy. After surgical recovery and education regarding device care, patients are discharged home. Meticulous care of the driveline must be taken to prevent infection and trauma of the site throughout the perioperative event and for the duration of support. Currently a standardized protocol for care of the driveline and exit site does not exist. VAD coordinators from across the country discussed the variability in care at different centers in the United States through a series of conference calls. A survey consisting of 16 questions was developed. The survey included questions on preoperative antibiotic recommendations, driveline placement and exit site suturing, frequency of dressing changes, and showering practices. VAD coordinators shared center-specific dressing protocols and any driveline success stories. This survey was sent to 73 centers; 38 centers (52%) responded. The purpose of the survey was to define current practice in order to move toward a standard of practice or protocol based on expert opinion for VAD driveline care and to assess the need for future studies.

Patient selection for ventricular assist devices: a moving target

The number of patients with advanced heart failure that has become unresponsive to conventional medical therapy is increasing rapidly. One of the most promising new alternatives to heart transplantation is use of ventricular assist devices (VADs). To date, there are no guidelines for appropriate selection for use of these devices that are approved by national societies in the field. This review addresses all of the general criteria for clinicians to keep in mind regarding when to refer a patient for evaluation and the specific issues addressed in patient selection. The field of mechanical circulatory support has advanced significantly over the past 10 years, resulting in rapid expansion of patients with advanced heart failure who can benefit from implantable devices. With progress of technology, limitations associated with age, body size, and comorbidities gradually become less prohibitive. The continuing simplification of design along with continued reduction in size of the devices, plus eventual elimination of the external drive line will make the use of VADs a superior option to heart transplant and even to medical management in many patients. We anticipate that the patient selection process outlined in the present review will continue to shift toward less advanced cases of heart failure.

Left ventricular assist device implantation in high risk destination therapy patients: an alternative surgical approach

Left Ventricular Assist Device (LVAD) for Destination Therapy (DT) is an established therapy for end stage heart failure patients who are not transplant candidates. Many DT patients requiring LVADs have had prior open heart surgery, the majority of whom had prior sternotomy. In addition, DT patients tend to be older and more likely to have more significant co-morbidities than their Bridge-To-Transplant (BTT) counterparts. As such, placement of an implantable LVAD in DT patients can be technically hazardous and potentially prone to more perioperative complications. The purpose of this report is to describe an alternative implantation approach for the implantation of the Heartmate II™ LVAD in high risk DT patients.

Left ventricular assist device-related infections: past, present and future

Over the last decade, left ventricular assist device (LVAD) implantation has emerged as an alternative treatment strategy in patients with advanced heart failure irrespective of their transplant eligibility. However, success and applicability of this therapy is largely limited by high complication rates associated with these devices. Although superior outcomes have been achieved with the second-generation continuous-flow LVADs, device-related infections continue to be a prevalent complication in this patient population and contribute significantly to the financial burden of this therapy due to an increased need for hospitalizations and surgical interventions. Patient selection, device design and LVAD-induced immune system dysfunction appear to be major risk factors for the development of device-related infections. Improvements in device design and better patient selection strategies, particularly with respect to identifying individuals with genetic susceptibility to device-related infections, may further reduce this prevalent complication and improve outcomes in patients with advanced heart failure.

Ventricular assist devices: pharmacological aspects of a mechanical therapy

Heart failure (HF) is a global epidemic that continues to cause significant morbidity and mortality despite advances in medical therapy. Ventricular assist device technology has emerged as a therapeutic option to bridge patients with end-stage HF to heart transplantation or as an alternative to transplantation in selected patients. In some patients, mechanical unloading induced by ventricular assist devices leads to improvement of myocardial function and a possibility of device removal. The implementation of this advanced technology requires multiple pharmacological interventions, both in the perioperative and long-term periods, in order to minimize potential complications and improve patient outcomes. We herein review the latest available evidence supporting the use of specific pharmacological interventions and current practices in the care of these patients: anticoagulation, bleeding management, pump thrombosis, infections, arrhythmias, right ventricular failure, hypertension, desensitization protocols, among others. Areas of uncertainty and ground for future research are also highlighted.

Clinical strategies and outcomes in advanced heart failure patients older than 70 years of age receiving the HeartMate II left ventricular assist device: a community hospital experience

OBJECTIVES

The primary objective of this study was to determine outcomes in left ventricular assist device (LVAD) patients older than age 70 years.

BACKGROUND

Food and Drug Administration approval of the HeartMate II (Thoratec Corporation, Pleasanton, California) LVAD for destination therapy has provided an attractive option for older patients with advanced heart failure.

METHODS

Fifty-five patients received the HeartMate II LVAD between October 5, 2005, and January 1, 2010, as part of either the bridge to transplantation or destination therapy trials at a community hospital. Patients were divided into 2 age groups: ≥ 70 years of age (n = 30) and < 70 years of age (n = 25). Outcome measures including survival, length of hospital stay, adverse events, and quality of life were compared between the 2 groups.

RESULTS

Pre-operatively, all patients were in New York Heart Association functional class IV refractory to maximal medical therapy. Kaplan-Meier survival for patients ≥ 70 years of age (97% at 1 month, 75% at 1 year, and 70% at 2 years) was not statistically different from patients <7 0 years of age (96% 1 month, 72% at 1 year, and 65% at 2 years, p = 0.806). Average length of hospital stay for the ≥ 70-year age group was 24 ± 15 days, similar to that of the < 70-year age group (23 ± 14 days, p = 0.805). There were no differences in the incidence of adverse events between the 2 groups. Quality of life and functional status improved significantly in both groups.

CONCLUSIONS

The LVAD patients ≥ 70 years of age have good functional recovery, survival, and quality of life at 2 years. Advanced age should not be used as an independent contraindication when selecting a patient for LVAD therapy at experienced centers.

Nutrition Implications of Heart Failure and Heart Transplantation in Children With Dilated Cardiomyopathy

This article describes nutrition implications of pediatric dilated cardiomyopathy leading to heart transplantation with a focus on nutritional management of patients during the waiting time for a donor organ and the inpatient postoperative period. Optimization of nutritional status is essential during these periods as weight loss and malnutrition contribute to muscle atrophy, decreased functional capacity, reduced immune function, and prolonged hospital stay. Nutrition implications of heart failure vary with patient’s age and degree of symptoms. Infants may have increased caloric needs and poor feeding often due to tachypnea. Older children, 1-18 years, may have decreased appetite, abdominal pain, and vomiting. Ventricular assist devices or extracorporeal membrane oxygenation, necessary to sustain life in some cases, have additional nutrition implications related to wound healing from insertion of the device and device-related complications that can include pancreatitis and the need for total parenteral nutrition. Once symptomatic heart failure is relieved and heart transplant occurs, caloric needs often decrease while interest in eating can increase profoundly, changing the overall nutrition diagnosis and the need for nutrition support. A case series involving an infant, a young child, and an adolescent is presented to illustrate nutritional challenges and interventions for pediatric patients awaiting heart transplant and the inpatient postoperative period.