Improving outcomes with long-term “destination” therapy using left ventricular assist devices

Expanding the heart donor pool: Can left ventricular assist devices substitute for marginal donor heart allografts?

BACKGROUND

Generally, heart transplantation with marginal donor allografts is reserved for a subset of high-risk patients. However, given the improved survival rates for patients on left ventricular assist devices, it is worth analyzing if they could potentially substitute for marginal donor allografts. This study aimed to compare survival outcomes of waitlisted patients with left ventricular assist devices who did not undergo heart transplantation to those who underwent heart transplantation with marginal allografts.

METHODS

This was a retrospective cohort study of adults (≥18 years) listed for heart transplantation between 2010 and 2022 in the Organ Procurement and Transplantation Network database. A previously validated risk score was used to define marginal donor organs. The primary outcome was death after transplantation or on the waitlist, as appropriate.

RESULTS

Of 5,713 patients with left ventricular assist devices, 4,683 (82%) comprised the left ventricular assist devices group and 1,030 (18%) the marginal group. The marginal cohort was older (57 [49-64] vs 55 [45-62] years, P < .001), similarly female (26 vs 24%, P = .16), and less often White (51 vs 60%, P < .001). Relative to the left ventricular assist devices group, the marginal group demonstrated higher 5-year survival from 2010 to 2014 (81 vs 43%, P < .001) and from 2015 to 2019 (77 vs 66%, P < .001). After adjustment, marginal patients demonstrated a significantly reduced hazard of 5-year mortality for those listed from 2010 to 2014 (hazard ratio 0.25, confidence interval 0.20-0.31; P < .001) and from 2015 to 2019 (hazard ratio 0.46, confidence interval 0.37-0.57; P < .001).

CONCLUSION

Our study validates the superiority of transplantation relative to left ventricular assist devices but also underscores the survival benefit of heart transplantation with marginal donor allografts, even in high-risk patients.

Unusual complications following left ventricular assisted device implantation: case series

Background

While left ventricular assisted devices (LVAD) have revolutionized the treatment of advanced heart failure, they are associated with a wide range of complications, including bleeding and infection which are the most common complications reported in the literature. Our case series report four unusual complications not related to gastrointestinal bleeding and infections and their management.

Case presentation

A 61 year old female after LVAD implantation with late onset of severe symptomatic aortic regurgitation treated by transfemoral transcatheter valve implantation (TAVI) with good long term results.

A 75 year old male patient with acute pump failure secondary to cable damage, who underwent urgent pump replacement. A 49 year old female patient with a history of myoma who developed massive uterine bleeding which was treated with emergent open hysterectomy after failed gonadotropin-releasing hormone therapy replacement. A 57 year old male patient with device display failure 1 month after LVAD implantation without the ability to monitor speed, power consumption and blood flow.

Conclusions

LVAD patients can be presented with a great variety of complications. Physicians should be aware of their manifestations and the management options.

Survival on the Heart Transplant Waiting List

Importance

With continuing improvements in medical devices and more than a decade since the 2006 United Network for Organ Sharing (UNOS) allocation policy, it is pertinent to assess survival among patients on the heart transplantation waiting list, especially given the recently approved 2018 UNOS allocation policy.

Objectives

To assess survival outcomes among patients on the heart transplant waiting list during the past 3 decades and to examine the association of ventricular assist devices (VADs) and the 2006 UNOS allocation policy with survival.

Design, Setting, and Participants

A retrospective cross-sectional used the UNOS database to perform an analysis of 95 323 candidates wait-listed for heart transplantation between January 1, 1987, and December 29, 2017. Candidates for all types of combined transplants were excluded (n = 2087). Patients were followed up from the time of listing to death, transplantation, or removal from the list due to clinical improvement. Competing-risk, Kaplan-Meier, and multivariable Cox proportional hazards regression analyses were used.

Main Outcomes and Measures

The analysis involved an unadjusted and adjusted survival analysis in which the primary outcome was death on the waiting list. Because of changing waiting list preferences and policies during the study period, the intrinsic risk of death for wait-listed candidates was assessed by individually analyzing, comparing, and adjusting for several candidate risk factors.

Results

In total, 95 323 candidates (72 915 men [76.5%]; mean [SD] age, 51.9 [12.0] years) were studied. In the setting of changes in listing preferences, 1-year survival on the waiting list increased from 34.1% in 1987-1990 to 67.8% in 2011-2017 (difference in proportions, 0.34%; 95% CI, 0.32%-0.36%; P < .001). The 1-year waiting list survival for candidates with VADs increased from 10.2% in 1996-2000 to 70.0% in 2011-2017 (difference in proportions, 0.60%; 95% CI, 0.58%-0.62%; P < .001). Similarly, in the setting of changing mechanical circulatory support indications, the 1-year waiting list survival for patients without VADs increased from 53.9% in 1996-2000 to 66.5% in 2011-2017 (difference in proportions, 0.13%; 95% CI, 0.12%-0.14%; P < .001). In the decade prior to the 2006 UNOS allocation policy, the 1-year waiting list survival was 51.1%, while in the decade after it was 63.9% (difference in proportions, 0.13%; 95% CI, 0.12%-0.14%; P < .001). In adjusted analysis, each time period after 1987-1990 had a marked decrease in waiting list mortality.

Conclusions and Relevance

This study found temporally associated increases in heart transplant waiting list survival for all patient groups (with or without VADs, UNOS status 1 and status 2 candidates, and candidates with poor functional status).

Management of combined pre- and post-capillary pulmonary hypertension in advanced heart failure with reduced ejection fraction

Management of pulmonary hypertension (PH) has remained an unmet need in advanced left heart failure with reduced ejection fraction. In fact, patients are frequently denied heart transplant due to untreated pulmonary hypertension. The availability of mechanically circulatory devices and PH therapies has provided a ray of hope. PH specific therapies are currently not FDA approved for patients with left heart failure with reduced ejection fraction. However, clinicians have used these medications in anecdotal manner. With this review, we want to highlight the expanding use of PH specific therapy and mechanical circulatory devices in the management of PH in the setting of advanced heart failure with reduced ejection fraction.

Palliative Medicine and Preparedness Planning for Patients Receiving Left Ventricular Assist Device as Destination Therapy-Challenges to Measuring Impact and Change in Institutional Culture

CONTEXT

Although left ventricular assist devices as destination therapy (DT-LVAD) can improve survival, quality of life, and functional capacity in well-selected patients with advanced heart failure, there remain unique challenges to providing quality end-of-life care in this population. Palliative care involvement is universally recommended, but how to best operationalize this care and measure success is unknown.

OBJECTIVES

To characterize the process of preparedness planning (PP) for patients receiving DT-LVAD at our institution and better understand opportunities for quality improvement or procedural transferability.

METHODS

Retrospective review of 107 consecutive patients undergoing DT-LVAD implantation at a single institution between 2009 and 2013. Information regarding demographics, advance care planning, and mortality was abstracted from the medical record and analyzed. Findings were compared with a historical cohort who received DT-LVAD implantation at the same institution before the development of PP (2003-2009).

RESULTS

Mean age of patients receiving DT-LVAD was 64.3 years (SD ± 10.7). At last follow-up, 46 patients (43%) had died. Mean post-DT-LVAD survival in this group was 1.1 years (SD ± 1.2). Eighty-nine percent of patient had palliative care consultation before implantation, and 70% completed PP. Although 66% of patients completed an advance directive (AD) preimplantation, only two ADs (2.8%) specifically mentioned DT-LVAD and none addressed core elements of PP. AD completion rates improved from 47% before our policy on PP (P = 0.012).

CONCLUSION

A disconnect was evident between the rigor of PP discussions and the content of ADs in the medical record. We urge that future efforts focus on narrowing this gap.

Rise of the Machines: In an Era of Ventricular Assist Devices, Prolonging Life or Death?

The past few decades witnessed the unprecedented "rise of the machines"; life-prolonging devices to support failing organs or as a form of organ replacement. Sophisticated machines provide us clinical milieu to intervene on sicker, dying patients, support the failing organ, prevent downward trajectory to multi-organ failure, and avert death. Hemodialysis has been in existence for several decades and has become the standard therapy for acute renal failure. Extracorporeal liver assist device replaces the detoxification function of the failing liver. Extracorporeal membrane oxygenator in cases of profound respiratory failure can replace the native lung function in the oxygenation of the venous blood and removal of carbon dioxide. The technology can also be used as a short-term heart-lung machine to keep the patient alive in the event of profound refractory cardiopulmonary collapse until the native heart and lung function returns. Ventricular assist devices (VADs) can completely replace the cardiac function in patients with end-stage heart failure and provide systemic flow. These innovative machines were developed under the assumption that they will improve survival, functional capacity, and quality of life in this cohort of patients. This case study focuses on the appropriate use of VADs as an alternative therapy for end-stage heart failure. This will explicate the ethical dilemma that concomitantly may arise with the use of these sophisticated organ replacement strategies when the goals of their placement are not met and just merely prolonging the dying process.

Palliative Care for the Geriatric Anesthesiologist

Many seriously ill geriatric patients are at higher risk for perioperative morbidity and mortality, and incorporating proactive palliative care principles may be appropriate. Advanced care planning is a hallmark of palliative care in that it facilitates alignment of the goals of care between the patient and the health care team. When these goals conflict, perioperative dilemmas can occur. Anesthesiologists must overcome many cultural and religious barriers when managing the care of these patients. Palliative care is gaining ground in several perioperative populations where integration with certain patient groups has occurred. Geriatric anesthesiologists must be aware of how palliative care and hospice influence and enhance the care of elderly patients.

Current state-of-the-art of device therapy for advanced heart failure

Heart failure remains one of the most common causes of morbidity and mortality worldwide. The advent of mechanical circulatory support devices has allowed significant improvements in patient survival and quality of life for those with advanced or end-stage heart failure. We provide a general overview of past and current mechanical circulatory support devices encompassing options for both short- and long-term ventricular support.

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.

Current approaches to device implantation in pediatric and congenital heart disease patients

The pediatric ventricular assist device (VAD) has recently shown substantial improvements in survival as a bridge to heart transplant for patients with end-stage heart failure. Since that time, its use has become much more frequent. With increasing utilization, additional questions have arisen including patient selection, timing of VAD implantation and device selection. These challenges are amplified by the uniqueness of each patient, the recent abundance of literature surrounding VAD use as well as the technological advancements in the devices themselves. Ideal strategies for device placement must be sought, for not only improved patient care, but also for optimal resource utilization. Here, we review the most relevant literature to highlight some of the challenges facing the heart failure specialist, and any physician, who will care for a child with a VAD.

Investigation of hemodynamics in an in vitro system simulating left ventricular support through the right subclavian artery using 4-dimensional flow magnetic resonance imaging

OBJECTIVES

Left ventricular assist devices are an important treatment option for patients with heart failure alter the hemodynamics in the heart and great vessels. Because in vivo magnetic resonance studies of patients with ventricular assist devices are not possible, in vitro models represent an important tool to investigate flow alterations caused by these systems. By using an in vitro magnetic resonance-compatible model that mimics physiologic conditions as close as possible, this work investigated the flow characteristics using 4-dimensional flow-sensitive magnetic resonance imaging of a left ventricular assist device with outflow via the right subclavian artery as commonly used in cardiothoracic surgery in the recent past.

METHODS

An in vitro model was developed consisting of an aorta with its supra-aortic branches connected to a left ventricular assist device simulating the pulsatile flow of the native failing heart. A second left ventricular assist device supplied the aorta with continuous flow via the right subclavian artery. Four-dimensional flow-sensitive magnetic resonance imaging was performed for different flow rates of the left ventricular assist device simulating the native heart and the left ventricular assist device providing the continuous flow. Flow characteristics were qualitatively and quantitatively evaluated in the entire vessel system.

RESULTS

Flow characteristics inside the aorta and its upper branching vessels revealed that the right subclavian artery and the right carotid artery were solely supported by the continuous-flow left ventricular assist device for all flow rates. The flow rates in the brain-supplying arteries are only marginally affected by different operating conditions. The qualitative analysis revealed only minor effects on the flow characteristics, such as weakly pronounced vortex flow caused by the retrograde flow via the brachiocephalic artery.

CONCLUSIONS

The results indicate that, despite the massive alterations in natural hemodynamics due to the retrograde flow via the right subclavian and brachiocephalic arteries, there are no drastic consequences on the flow in the brain-feeding arteries and the flow characteristics in the ascending and descending aortas. It may be beneficial to adjust the operating condition of the left ventricular assist device to the residual function of the failing heart.

Family caregivers' inside perspectives: caring for an adult with a left ventricular assist device as a destination therapy

CONTEXT

Understanding the experience of caring for an adult with a left-ventricular assist device as a destination therapy (LVAD-DT) remains in its infancy.

OBJECTIVE/DESIGN

A hermeneutic-phenomenological inquiry guided by van Manen's methods was used to explore the LVAD-DT family caregiving experience.Participants/Setting-Seven family caregivers (1 man and 6 women) 50 to 74 years old who cared for an adult with an LVAD-DT in home settings. Recruitment and data collection occurred in an outpatient mechanical circulatory support center in the Midwest.

METHODS

Data were collected by means of face-to-face interviews using open-ended questions and 1 follow-up interview. Interviews were audio recorded and transcribed verbatim. Thematic analysis consisted of writing, rewriting, and reflecting across participants' data, which produced themes illustrating the experience and meaning of caring for an adult with an LVAD-DT. Themes were consensually validated. Procedures for trustworthiness are described.

RESULTS

Five main themes were identified from participants' experiences: (1) advanced heart failure is a life-changing event, (2) self-doubt about LVAD caregiving improves over time, (3) lifestyle adjustments come with time, (4) persistent worry and stress, and (5) caregiving is not a burden-it's a part of life. These main themes were elucidated by 8 subthemes in which participants described a process of adjustment despite persistent worry and stress and eventually accepted caregiving as part of their lives. Future studies are needed to explore caregiver burden, adaptation, and the effects of caregiving outcomes, such as emotional and physical health and overall quality of life.

End-of-life care in patients with heart failure

Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF range from continuation of guideline-directed medical therapy to device interventions and cardiac transplantation. However, patients approaching the end of life may elect to forego therapies or procedures perceived as burdensome, or to deactivate devices that were implanted earlier in the disease course. Although discussing end-of-life issues such as advance directives, palliative care, or hospice can be difficult, such conversations are critical to understanding patient and family expectations and to developing mutually agreed-on goals of care. Because patients with HF are at risk for rapid clinical deterioration or sudden cardiac death, end-of-life issues should be discussed early in the course of management. As patients progress to advanced HF, the need for such discussions increases, especially among patients who have declined, failed, or been deemed to be ineligible for advanced HF therapies. Communication to define goals of care for the individual patient and then to design therapy concordant with these goals is fundamental to patient-centered care. The objectives of this white paper are to highlight key end-of-life considerations in patients with HF, to provide direction for clinicians on strategies for addressing end-of-life issues and providing optimal patient care, and to draw attention to the need for more research focusing on end-of-life care for the HF population.

An insight into short- and long-term mechanical circulatory support systems

Cardiogenic shock due to acute myocardial infarction, postcardiotomy syndrome following cardiac surgery, or manifestation of heart failure remains a clinical challenge with high mortality rates, despite ongoing advances in surgical techniques, widespread use of primary percutaneous interventions, and medical treatment. Clinicians have, therefore, turned to mechanical means of circulatory support. At present, a broad range of devices are available, which may be extracorporeal, implantable, or percutaneous; temporary or long term. Although counter pulsation provided by intra-aortic balloon pump (IABP) and comprehensive mechanical support for both the systemic and the pulmonary circulation through extracorporeal membrane oxygenation (ECMO) remain a major tool of acute care in patients with cardiogenic shock, both before and after surgical or percutaneous intervention, the development of devices such as the Impella or the Tandemheart allows less invasive forms of temporary support. On the other hand, concerning mid-, or long-term support, left ventricular assist devices have evolved from a last resort life-saving therapy to a well-established viable alternative for thousands of heart failure patients caused by the shortage of donor organs available for transplantation. The optimal selection of the assist device is based on the initial consideration according to hemodynamic situation, comorbidities, intended time of use and therapeutic options. The present article offers an update on currently available mechanical circulatory support systems (MCSS) for short and long-term use as well as an insight into future perspectives.

Ethical dilemmas surrounding the use of ventricular assist devices in supporting patients with end-stage organ dysfunction

Successful practice of cardiovascular medicine requires familiarity with the complex ethical issues that accompany therapeutic innovation and diffusion. Even as technologies transition from experimental to standard care, challenges remain. Mechanical circulatory support devices, for instance, are increasingly conceptualized as conventional therapies. Despite this, or perhaps because of it, the ethical issues surrounding the use of these devices in patients with end-stage organ dysfunction are becoming increasingly apparent. In this paper, we provide an introduction to ethical considerations related to the use of ventricular assist devices (VADs) in end-stage organ failure, focusing on three stages or decision points: initiation, continued use, and deactivation. Our goal is not to exhaustively resolve these dilemmas but to illustrate how ethical considerations relate to decision making.

Mechanical circulatory support: devices, outcomes and complications

Systolic heart failure is a problem of substantial magnitude worldwide. Over the last 25 years great progress has been made in the medical management of heart failure with the recognition of the benefits of beta-adrenergic blockade, modulation of the renin-angiotensin and mineralocorticoid axes and judicious diuretic therapy. In addition, cardiac resynchronization therapy and prophylactic implantation of cardiac defibrillators have been responsible for measurable benefits in terms of functional status and dysrhythmia-related mortality, respectively. Unfortunately, progressive cardiac dysfunction often results in activity limitation, symptoms at rest, hospital admission, end-organ dysfunction and death despite maximal implementation of standard therapies. Heart transplantation has been a dramatic and effective therapy for end-stage heart failure, but it remains limited by a shortage of donor organs, strict criteria defining acceptable recipients and often unsatisfactory long-term success. Mechanical alternatives to support the failing circulation have been sought for the last 50 years. The history of device development has been marked in general by the slow progress achieved by a few dedicated and persevering pioneers. In the past decade, however, evolving technology has dramatically changed the field and broadened the options for the treatment of advanced heart failure. This review will detail the important milestones and the current state of the art, with an emphasis on implantable devices for intermediate to long term support.

The spectrum of complications following left ventricular assist device placement

INTRODUCTION

Left ventricular assist device (LVAD) support is associated with many complications, but relatively few studies have examined the full spectrum of complications beyond infectious and bleeding events.

METHODS

We conducted a retrospective review of patients receiving either a pulsatile-flow Heartmate XVE (HM1; Thoratec Corp., Pleasanton, CA, USA) or continuous-flow Heartmate II (HM2; Thoratec Corp.) LVAD at our institution (June 2000 to March 2012). Frequency and date of onset of nonbleeding, noninfectious complications were examined.

RESULTS

One hundred eighty-two LVADs were implanted, 49 HM1, and 133 HM2. Support duration was longer for HM2s (median 358 vs. 112 days; p = 0.0003). Overall, the most frequent complications were respiratory failure, ventricular arrhythmia, atrial arrhythmia, right heart failure, and renal failure. Respiratory failure, arrhythmias, severe psychiatric events, and renal failure all occurred with median date of onset ≤ seven days postprocedure. Right heart failure, hepatic failure, thromboembolism, and transient ischemic attacks had a median date of onset 8 to 30 days postprocedure. Stroke, hemolysis, and device failure occurred mostly more than a month postoperatively. Right heart failure, hepatic failure, and device failure were more frequent in HM1 patients than in HM2 patients. Several events, including stroke, had much later onset in HM2 patients.

CONCLUSION

In this 10-year review of complications following LVAD implantation, the most common adverse events tended to occur early after implantation. As pulsatile-flow HM1s showed greater frequency and earlier onset of some adverse events, our data suggest better overall outcomes with the continuous-flow HM2s.

Overcoming alterations in body image imposed by the left ventricular assist device: a case report

Little is known about clothing issues among patients with implantable left ventricular assist devices (LVADs). This article describes the experience of a woman who had challenges in adapting to an altered body image imposed by the external components of the LVAD system. The woman discusses her problems about clothes that fit her personal style and shares her strategies and recommendations in overcoming the problem. Her description of how she approached and resolved the problem is situated within the Apparel Body Construct Model. In this context, appropriate selection of apparrel is crucial not only to preserving the integrity and function of the LVAD system but also to the recipient's satisfaction with her body image. The information presented is a catalyst for knowledge development and heightening health care providers' awareness of patients' perception of body image, which is vital to adapting to an LVAD as a component of the recipient's body and life.

Current status of mechanical circulatory support: a systematic review

Heart failure is a major public health problem and its management requires a significant amount of health care resources. Even with administration of the best available medical treatment, the mortality associated with the disease remains high. As therapeutical strategies for heart failure have been refined, the number of patients suffering from the disease has expanded dramatically. Although heart transplantation still represents the gold standard therapeutical approach, the implantation of mechanical circulatory support devices (MCSDs) evolved to a well-established management for this disease. The limited applicability of heart transplantation caused by a shortage of donor organs and the concurrent expand of the patient population with end-stage heart failure led to a considerable utilization of MCSDs. This paper outlines the current status of mechanical circulatory support.

New era for therapeutic strategy for heart failure: destination therapy by left ventricular assist device

Until 2010, Japan had been using the Toyobo (Nipro, Osaka, Japan) extracorporeal left ventricular assist device (VAD) developed 30 years ago as a 2-3 year bridge to transplantation (BTT). In contrast, western nations started to use implantable VADs in the 1980s that allow in-home care as destination therapy (DT) as well as BTT. Designated in 2007 as "medical devices in high demand," the 5 major implantable mechanical hearts are smoothly undergoing clinical testing. The HeartMate XVE (Thoratec Corp., Pleasanton, CA, USA) gained approval from the Ministry of Health in November of 2009, the DuraHeart (TerumoHeart, Ann Arbor, MI, USA) and EVAHEART (Sun Medical, Nagano, Japan) in December 2010, and obtained formal insurance reimbursement in April 2011. The Jarvik 2000 (Jarvik Heart Inc., New York, NY, USA) and HeartMate II (Thoratec) VADs are pending approval. On the other hand, the organ transplantation law allowing explantation of donor organs from brain-dead patients finally passed in July 2009 and was realized in July 2010. This law paved the way to pediatric heart transplants as well as a dramatic increase in overall organ transplantation cases. Because many juvenile patients awaiting donor organs need a VAD as a long-term bridge, development and clinical introduction of pediatric VADs capable of implantation is an exigency. Although expectations for transplants are high, the donor numbers are low. Therefore, the demand for implantable VADs capable of long-term home treatment is extremely high in Japan.

Effective ventricular unloading by left ventricular assist device varies with stage of heart failure: cardiac simulator study

Although the use of left ventricular assist devices (LVADs) as a bridge-to-recovery (BTR) has shown promise, clinical success has been limited due to the lack of understanding the timing of implantation, acute/chronic device setting, and explantation. This study investigated the effective ventricular unloading at different heart conditions by using a mock circulatory system (MCS) to provide a tool for pump parameter adjustments. We tested the hypothesis that effective unloading by LVAD at a given speed varies with the stage of heart failure. By using a MCS, systematic depression of cardiac performance was obtained. Five different stages of heart failure from control were achieved by adjusting the pneumatic systolic/diastolic pressure, filling pressure, and systemic resistance. The Heart Mate II® (Thoratec Corp., Pleasanton, CA) was used for volumetric and pressure unloading at different heart conditions over a given LVAD speed. The effective unloading at a given LVAD speed was greater in more depressed heart condition. The rate of unloading over LVAD speed was also greater in more depressed heart condition. In conclusion, to get continuous and optimal cardiac recovery, timely increase in LVAD speed over a period of support is needed while avoiding the akinesis of aortic valve.

Maximal care considerations when treating patients with end-stage heart failure: ethical and procedural quandaries in management of the very sick

Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient's best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure.

Endoscopic findings and clinical outcomes in ventricular assist device recipients with gastrointestinal bleeding

BACKGROUND

Gastrointestinal bleeding (GIB) is an important clinical problem in recipients of ventricular assist devices (VAD), although data pertaining to the endoscopic evaluation and management of this complication are limited in the medical literature.

AIMS

We sought to identify the most common endoscopic findings in VAD recipients with GIB, and to better define the diagnostic and therapeutic utility of endosopy for this patient population.

METHODS

Twenty-six subjects with VAD and overt GIB were retrospectively identified. Clinical and endoscopic data were abstracted for each subject on to standardized forms in duplicate and independent fashion. Raw data and descriptive statistics were reported.

RESULTS

Non-peptic vascular lesions were the most common cause of GIB. A definitive cause of bleeding was identified by endoscopy in almost 60% of subjects. Endoscopic hemostasis was achieved in 14/15 patients in whom bleeding did not stop spontaneously. Rebleeding occurred in 50% of subjects and was successfully retreated or stopped spontaneously in all cases. Colonoscopy did not establish a definitive diagnosis or deliver hemostatic therapy in any case.

CONCLUSIONS

Vascular malformations account for the overwhelming majority of bleeding lesions in VAD patients with GIB. Endoscopy seems to be a safe and effective tool for diagnosing, risk stratifying, and treating this patient population, although multiple endoscopies may be necessary before therapeutic success, and the incidence of rebleeding is high. A prospective multi-center registry is necessary to establish evidence-based management algorithms for VAD recipients with GIB.

Palliative care and hospice in advanced heart failure

Advanced heart failure (HF) is a disease process that carries a high burden of symptoms, suffering, and death. Palliative care can complement traditional care to improve symptom amelioration, patient-caregiver communication, emotional support, and medical decision making. Despite a growing body of evidence supporting the integration of palliative care into the overall care of patients with HF and some recent evidence of increased use, palliative therapies remain underused in the treatment of advanced HF. Review of the literature reveals that although barriers to integrating palliative care are not fully understood, difficult prognostication combined with caregiver inexperience with end-of-life issues specific to advanced HF is likely to contribute. In this review, we have outlined the general need for palliative care in advanced HF, detailed how palliative measures can be integrated into the care of those having this disease, and explored end-of-life issues specific to these patients.

Religion and the Catholic church's view on (heart) transplantation: a recent statement of Pope Benedict XVI and its practical impact

Heart transplantation is performed on approximately 4,000 patients per year worldwide and is considered the last resort for treatment of end-stage heart diseases. Due to persistent organ shortage, resources are limited, waiting periods are extensive, and patients still die while being on a waiting list for transplantation. The role of all churches and the support of the representatives of the churches are critical for the spiritual wellbeing of patients awaiting heart transplantation as well as for prospective individual organ donors and their families. The supportive role of the Roman Catholic Church and the recent statement of Pope Benedict XVI on organ donation are discussed.

Palliative medicine consultation for preparedness planning in patients receiving left ventricular assist devices as destination therapy

OBJECTIVE

To assess the benefit of proactive palliative medicine consultation for delineation of goals of care and quality-of-life preferences before implantation of left ventricular assist devices as destination therapy (DT).

PATIENTS AND METHODS

We retrospectively reviewed the cases of patients who received DT between January 15, 2009, and January 1, 2010.

RESULTS

Of 19 patients identified, 13 (68%) received proactive palliative medicine consultation. Median time of palliative medicine consultation was 1 day before DT implantation (range, 5 days before to 16 days after). Thirteen patients (68%) completed advance directives. The DT implantation team and families reported that preimplantation discussions and goals of care planning made postoperative care more clear and that adverse events were handled more effectively. Currently, palliative medicine involvement in patients receiving DT is viewed as routine by cardiac care specialists.

CONCLUSION

Proactive palliative medicine consultation for patients being considered for or being treated with DT improves advance care planning and thus contributes to better overall care of these patients. Our experience highlights focused advance care planning, thorough exploration of goals of care, and expert symptom management and end-of-life care when appropriate.

Evaluation of right ventricular function and post-operative findings using cardiac computed tomography in patients with left ventricular assist devices

BACKGROUND

Right ventricular (RV) failure is a major contributor to morbidity and mortality after left ventricular assist device (LVAD) implantation. Accurate evaluation of RV function in patients with LVAD remains challenging. We hypothesized that, after LVAD implantation, electrocardiographic-gated cardiac computed tomography (CCT) allows RV evaluation with higher feasibility and reproducibility compared with echocardiography.

METHODS

Thirty-six patients with an implanted LVAD who had 2-dimensional echocardiography and CCT evaluation were studied. RV end-diastolic and end-systolic volumes and ejection fraction were quantified using CCT. RV fractional area change, tricuspid annular plane systolic excursion and RV end-diastolic short-to-long axis ratio were calculated by echocardiography. Intraclass correlation coefficients (ICCs) and Bland-Altman analysis were used to assess intra- and interobserver reproducibility for all measurements.

RESULTS

The quality of CCT studies was good in all cases except for one. Intra- and interobserver reproducibility for all CCT measurements was high (interobserver ICC for RV ejection fraction = 0.89, 95% confidence interval 0.74 to 0.95). Echocardiographic indices of RV function and geometry had lower reproducibility. The echocardiographic index that best correlated with the CCT-determined RV ejection fraction was RV fractional area change (r = 0.80, p < 0.001). In addition, CCT detected relevant post-operative findings in 50% of the patients.

CONCLUSIONS

CCT is highly effective and reproducible compared with echocardiography for the evaluation of RV function in patients with LVAD support and provides relevant information on post-operative findings. Our results suggest that CCT should be considered as a useful imaging modality in this clinical setting.

Mechanical circulatory support as a bridge to transplant or for destination therapy

Mechanical circulatory support (MCS) frequently is used to treat medically refractory end-stage heart failure. Initially designed to be a bridge to transplantation, MCS also has proven itself as a durable therapy for patients who are not transplant candidates. As outcomes for patients with MCS have improved, research interest in device development has flourished, with many new device types under investigation. In addition to improvement of MCS devices, investigational work continues to achieve appropriate patient selection and complication management.

Improvement in 2-year survival for ventricular assist device patients after implementation of an intensive surveillance protocol

BACKGROUND

This study was conducted to determine the effect of a disease-management model termed an "intensive surveillance protocol" (ISP) on survival in ventricular assist device (VAD) patients. This intervention consisted of a formalized, protocol-driven, multi-disciplinary team approach to VAD patient follow-up initiated August 1, 2006. The goal was to attain an internal program benchmark of 70% survival at 2 years. Historically, 2-year survival after VAD implant has been sub-optimal, and no patient management algorithms have been formally tested to determine their effect on 2-year survival.

METHODS

The study comprised 76 patients, of whom 26 had a VAD as destination therapy (DT) and 50 as a bridge to transplant (BTT), from July 1, 2003, to June 30, 2008. Survival before and after initiation of ISP was compared. A parametric hazard multivariable analysis, with a time-varying covariable for implementation of ISP, was used to evaluate of other factors affecting survival.

RESULTS

Survival at 16 months was 100% for DT patients who received a VAD after August 1, 2006 vs 64% for the earlier era (p = 0.06). For BTT, 16- month survival was 71% vs 43% (p = 0.03). Predicted 2-year survival before and after implementation of the ISP improved from 30% to 87% for DT (p = 0.02) and from 20% to 61% for BTT patients (p = 0.01). Predictors of midterm survival by multivariable analysis included ISP (p = 0.004), younger age (p = 0.03), non-emergent implant (p < 0.0001), and isolated left ventricular VAD (p < 0.0001). After adjustment for covariables, the ISP was associated with a 70% reduction in the hazard for death for the entire cohort (p = 0.004). The effect of ISP was also significant in the patients who received the HeartMate XVE (Thoratec, Pleasanton, CA), which spanned both eras of the study.

CONCLUSIONS

Survival improved for DT and BTT VAD patients after implementation of the ISP, with a dramatic decrease in hazard for death. Although the transition from pulsatile to axial flow technology occurred during the study period and likely contributed to improved outcomes, the institution of the ISP provided an important and significant contribution to improved survival through a proactive approach to patient management, allowing earlier identification of potential adverse events. For optimal outcomes, VAD patients require intensive follow-up surveillance protocols that have previously become standard in the care of heart transplant patients.

A two-round Delphi study examining consensus of recommended clinical practices for patients with ventricular assist devices as destination therapy

OBJECTIVE

To identify the current clinical practices of Medicare-certified facilities offering ventricular assist devices as destination therapy and to attain a consensus of recommended clinical practices across the United States for the management of adults with ventricular assist devices as destination therapy.

METHOD

Sixty ventricular assist device coordinators from Medicare-certified centers were invited to participate in an online, 2-round Delphi survey. The surveys asked whether recommended practices are current practices and whether respondents always/agreed or never/disagreed with performing the recommended practice guidelines. Consensus was defined as 75% agreement. The clinical areas of focus were patient selection, preoperative preparation, postoperative care, infection control, nutrition, and patient discharge preparation. Practices were extracted from the advanced practice guidelines for HeartMate destination therapy and the International Society for Heart and Lung Transplantation's 2006 guidelines for the care of heart transplant candidates.

RESULTS

Representing 21 states across the country, the first-round survey had a response rate of 57% (n = 34). The second-round survey had a response rate of 74% (n = 17), representing 28% of the 60 centers. Consensus was obtained for 122 practices. The dimension of patient selection-diagnostic tests and screening had the highest level of consensus (16%, n = 20), and the dimension of postoperative care-intermediate/intensive care unit dimension had the lowest level of consensus (3.3%, n = 4).

CONCLUSION

Survey results identify a consensus of practices for the specific group of ventricular assist device coordinators who responded, but that consensus cannot be generalized to all ventricular assist device facilities. These results can, however, provide a foundation for further research leading to the development of standard-of-care practices for patients with ventricular assist devices as destination therapy.

Use of gated cardiac computed tomography angiography in the assessment of left ventricular assist device dysfunction

The purpose of this study is to describe the utility and limitations of gated contrast-enhanced cardiac computed tomography angiography in assessing left ventricular assist device function. Computed tomography angiography (CTA) was used in 14 patients with left ventricular assist devices (LVADs) who had persistent heart failure symptoms, hemodynamic instability, or potential problems with LVAD flows. Retrospectively gated contrast-enhanced CTA was performed on 64-detector scanner, and the CTA images were postprocessed in multiple curved projections on TeraRecon workstation. This study describes the use of CTA to identify LVAD-related issues that altered clinical management and explores the role of CTA and other techniques in evaluating LVAD function. Six of 14 LVAD patients who demonstrated no abnormality on CTA remained stable with medical management. In the remaining eight patients, CTA was abnormal, including abnormalities specifically related to the LVAD cannula. As a result of findings detected by CTA, six patients underwent surgical intervention, including device exchange and heart transplant. Computed tomography angiography is a noninvasive method that enhances diagnostic evaluation of patients with suspected LVAD dysfunction and can lead to changes in patient management.

End-of-life decision making and implementation in recipients of a destination left ventricular assist device

BACKGROUND

The use of left ventricular assist devices (LVADs) as destination therapy (DT) is increasing and has proven beneficial in prolonging survival and improving quality of life in select patients with end-stage heart failure. Nonetheless, end-of-life (EOL) issues are inevitable and how to approach them underreported.

METHODS

Our DT data registry was queried for eligible patients, defined as those individuals who actively participated in EOL decision making. The process from early EOL discussion to palliation and death was reviewed. We recorded the causes leading to EOL discussion, time from EOL decision to withdrawal and from withdrawal to death, and location. Primary caregivers were surveyed to qualify their experience and identify themes relevant to this process.

RESULTS

Between 1999 and 2009, 92 DT LVADs were implanted in 69 patients. Twenty patients qualified for inclusion (mean length of support: 833 days). A decrease in quality of life from new/worsening comorbidities usually prompted EOL discussion. Eleven patients died at home, 8 in the hospital and 1 in a nursing home. Time from EOL decision to LVAD withdrawal ranged from <1 day to 2 weeks and from withdrawal until death was <20 minutes in all cases. Palliative care was provided to all patients. Ongoing assistance from the healthcare team facilitated closure and ensured comfort at EOL.

CONCLUSIONS

With expanding indications and improved technology, more DT LVADs will be implanted and for longer durations, and more patients will face EOL issues. A multidisciplinary team approach with protocols involving DT patients and their families in EOL decision making allows for continuity of care and ensures dignity and comfort at EOL.

A Two-Round Delphi Study Examining Consensus of Recommended Clinical Practices for Patients with Ventricular Assist Devices as Destination Therapy

Objective

To identify the current clinical practices of Medicare-certified facilities offering ventricular assist devices as destination therapy and to attain a consensus of recommended clinical practices across the United States for the management of adults with ventricular assist devices as destination therapy.

Method

Sixty ventricular assist device coordinators from Medicare-certified centers were invited to participate in an online, 2-round Delphi survey. The surveys asked whether recommended practices are current practices and whether respondents always/agreed or never/disagreed with performing the recommended practice guidelines. Consensus was defined as 75% agreement. The clinical areas of focus were patient selection, preoperative preparation, postoperative care, infection control, nutrition, and patient discharge preparation. Practices were extracted from the advanced practice guidelines for HeartMate destination therapy and the International Society for Heart and Lung Transplantation's 2006 guidelines for the care of heart transplant candidates.

Results

Representing 21 states across the country, the first-round survey had a response rate of 57% (n = 34). The second-round survey had a response rate of 74% (n= 17), representing 28% of the 60 centers. Consensus was obtained for 122 practices. The dimension of patient selection—diagnostic tests and screening had the highest level of consensus (16%, n = 20), and the dimension of postoperative care—intermediate/intensive care unit dimension had the lowest level of consensus (3.3%, n = 4).

Conclusion

Survey results identify a consensus of practices for the specific group of ventricular assist device coordinators who responded, but that consensus cannot be generalized to all ventricular assist device facilities. These results can, however, provide a foundation for further research leading to the development of standard-of-care practices for patients with ventricular assist devices as destination therapy.

Achieving medical stability: Wives' experiences with heart failure

The incidence of heart failure continues to rise as innovative treatments are developed. Despite life-prolonging interventions, morbidity and mortality in patients younger than 65 remain high. Few studies have focused on this younger cohort and/or their family caregivers as they navigate the complex illness trajectories manifested in heart failure. Instrumental case studies were employed to present exemplars for each of the five identified heart failure trajectories. Culling data from a longitudinal study of female spousal caregivers, each case study represents a wife's discussion of caring for a husband (<65 years) in response to the husband's changing heart failure trajectory. The goal of medical stability and the notion of uncertainty permeate throughout the case studies. Suggestions for supporting these wives are presented.

Non-pulsatile circulation with axial-flow left ventricular assist device preserves neurocognitive function

Concerns about the potential impact of the non-pulsatile circulation pattern generated by the new generation axial-flow left ventricular assist devices on neurocognitive function led us to evaluate a patient in whom a Jarvik 2000 pump was implanted. We assessed the patient’s baseline neurocognitive function preoperatively as well as at 1-month and 6-month follow-up, using a comprehensive battery of neuropsychological tests. A slight improvement in circumscribed neurocognitive domains was noted, with no evidence of further decline at the end of a 6-month follow-up period.