Use of Left Ventricular Assist Device (HeartMate II): A Singapore Experience

Comparative analysis of survival rate and quality of life in axial-flow pump left ventricular assist devices (LVADs)

BACKGROUND

The rising heart failure rates globally show the pressing demand for treatment progress, especially in Left Ventricular Assist Devices (LVADs). Axial-flow pump LVADs are gaining notice for their small size, few moving parts, and potential for miniaturization, providing a vital option for heart transplants during donor shortages.

OBJECTIVES

Despite several studies on LVADs, there is a notable lack of research specifically comparing axial-flow pumps with similar technology. This gap hinders the identification of the most optimal technology to guide development efforts and meet patient needs. This study aims to comprehensively compare the most commonly used axial-flow pumps and provide a detailed analysis focusing on survival rates and quality of life parameters.

METHODS

As a developer of axial-flow pumps (LVADs), our group conducted a systematic review of the current axial-flow pump LVADs. We analyzed studies comparing these devices, focusing on key metrics such as survival rates and quality of life.

RESULTS

The HeartMate 2 and Jarvik 2000 show superior survival rates (up to 86.9 % at 6 months, 96.3 % at 3 years) and (6-month survival 67 %-91 %) respectively, compared to the other axial flow pumps LVAD. The results underscore the importance of choosing the optimal device and informing the direction of future developments.

CONCLUSION

In this paper, we aim to inform future studies to enhance their effectiveness and advance the overall performance of these devices, ultimately benefiting patients and developers. This review furnishes evidence-based recommendations for the most appropriate axial-flow pumps based on survival rates and quality of life parameters.

Deciding to Live (or Not) With a Left Ventricular Assist Device-a Thematic Analysis Exploring Factors Influencing the Decision-Making Process in Advanced Heart Failure Patients in Singapore

Background: It is often difficult for patients with advanced heart failure (HF) to decide whether to live with a left ventricular assist device (LVAD) or not. Little is known about their decisional needs prior to LVAD implantation and if these needs were met in the Asian cultural setting. Aims: We aimed to explore the influences, concerns, and needs surrounding the decision-making process of the LVAD implantation among multi-ethnic Asian patients with HF. Methods: Semi-structured interviews with HF patients and caregivers were conducted, based upon the grounded theory approach. Participants were purposively recruited from the inpatient and outpatient setting of the National Heart Centre Singapore. Results: A total of 31 patients and 11 caregivers participated. Mindsets that shaped decision-making ranged from "having no choice," "being reflective," "taking a gamble," and "fighting on." Instead of making a sole decision, many patients reported that decisions were shared with the family or medical team. Current LVAD patients who acted as patient ambassadors were also strong influences. Spiritual support was pivotal to decision-making for some participants. Goals influencing decision-making including protecting the family and life prolongation improving quality of life. Values held close included sanctity of life, trusting in a higher power, believing in pre-destination or karma, and preserving family harmony. Participants had concerns about cost, employment, and health outcomes. Conclusions: Asian LVAD patients and caregivers had culturally specific mindsets, goals, and values and concerns around decision-making. Our findings have implications for the design of interventions and supportive care models.

5-year results of a newly implemented mechanical circulatory support program for terminal heart failure patients in a Swiss non-cardiac transplant university hospital

Background

In Switzerland, long-term circulatory support programs have been limited to heart transplant centers. In 2014, to improve the management of patients with end-stage heart failure not eligible for transplantation, we implemented a left ventricular assist device (LVAD) program for destination therapy at the University Hospital of Basel.

Methods

We described the program set-up with practical aspects. Patients aged 65 and above with therapy refractory end-stage heart failure without major contraindication for LVAD implantation were included. Younger patients with bridge-to-candidacy profile were also considered. Using the Kaplan-Meier estimate, we retrospectively analyzed the overall survival and freedom from major adverse events after LVAD implantation. We compared our results to internationally reported data.

Results

Between October 2014 and September 2019, 16 patients received an LVAD in our center. The mean age at implantation was 67.1 years. The mean EuroSCORE II was 24.4% and the median INTERMACS level was 4. Thirteen patients received an LVAD as destination therapy and three patients as bridge-to-candidacy. The overall survival was 87.5 and 70% at 1 and 2 years, respectively. Freedom from stroke was 81.3% at 1 and 2 years. Freedom from device infection was 67.7 and 58.7% at 1 and 2 years, respectively. Freedom from gastrointestinal bleeding was 75 and 56.3% at 1 and 2 years, respectively. Freedom from readmission was 50 and 31.3% and at 6 months and 1 year, respectively.

Conclusions

The Basel experience demonstrated the possible implementation of an LVAD program for destination therapy or bridge-to-candidacy in a non-transplant comprehensive heart-failure center with midterm survival results and freedom from major adverse events comparable to international registries. Patient selection remains crucial.

Trial registration

This study was registered on the ClinicalTrials.gov database (NCT04263012).

Lived Experiences and Long-Term Challenges and Needs of Asian Left Ventricular Assist Device Caregivers

Background: Caregivers are essential for improved outcomes in patients living with left ventricular assist device (LVAD). There is a paucity of research on a long-term LVAD caregivers' experiences and burdens.

Objectives: The aim of this study was to explore long-term challenges and needs of LVAD caregivers in the Asian health care setting.

Design: We conducted semistructured interviews with caregivers of patients who were currently or previously living with the LVAD.

Settings/Subjects: Caregivers were recruited from the National Heart Centre Singapore.

Measurements: Interviews were conducted in English and Chinese. All interviews were transcribed verbatim and analyzed based on grounded theory. Chinese interviews were translated to English before transcription.

Results: A multiethnic and multireligious sample of 11 caregivers participated. Median caregiving duration was 45 months. Caregivers described long-term challenges that were multifaceted. Misaligned patient expectations, stigmatization and limited social resources within the family and society affected caregivers' coping. Existing gender roles and spiritual and cultural influences shaped how caregivers appraised, made meaning of caregiving, and assessed support. Long-term caregivers' needs included learning from role models, shifting perspectives, enhancing communication between patient and caregivers, advocacy efforts, and holistic medical care.

Conclusions: Gender roles as well as cultural and spiritual influences affected coping and access to support in long-term Asian LVAD caregivers. Future interventions should consider culturally relevant approaches to improve well-being and quality of life of caregivers.

Use of durable left ventricular assist devices for high-risk patients: Korean experience before insurance coverage

Background

Left ventricular assist devices (LVADs) were not covered by the Korean national insurance until September 2018, and they were implanted at the patient’s own or a third party’s expense. However, there have been no reports on using an LVAD without insurance coverage or manufacturer support.

Methods

We reviewed 23 patients who underwent durable LVAD implantation at our institution from August 2012 to September 2018. Patients with temporary LVADs using extracorporeal or paracorporeal circulation were excluded. The available devices were the HeartMate II^TM (HMII) and HeartWare^TM Ventricular Assist Device (HVAD). The primary outcome was 30-day mortality. The secondary outcomes were postoperative complications and late mortality.

Results

The mean age of the patients was 68.7±9.9 years. The study sample comprised six female (26.1%) and 17 male (73.9%) patients. All patients had modifiable (bridge to candidacy) or unmodifiable absolute (destination therapy) contraindications for heart transplantation (HT). Among the patients in this study, 12 (52.2%) had ischemic cardiomyopathy and 11 (47.8%) had non-ischemic cardiomyopathy. Nine patients (39.1%) had temporary mechanical circulatory support such as extracorporeal membrane oxygenation or a temporary LVAD in place preoperatively. The average duration of LVAD support was 618.6±563.2 days (range, 59–2,285 days). There was no 30-day mortality. Four patients (17.4%) underwent HT. Six patients (26.1%) underwent re-exploration for postoperative bleeding, and one patient (4.3%) had a disabling stroke after discharge. The estimated survival rates at 12 and 24 months were 89.2% and 68.8%, respectively.

Conclusions

All patients who received LVADs before insurance coverage had contraindications for HT. The overall outcomes were comparable with those reported in the international registry.

Life Beyond Heart Failure-What Are the Long-Term Challenges, Supportive Care Needs, and Views Toward Supportive Care of Multiethnic Asian Patients With Left Ventricular Assist Device and Their Caregivers?

CONTEXT

Challenges experienced by patients with the left ventricular assist device (LVAD) and their caregivers during the early period after LVAD implantation are well documented. However, little is known about long-term challenges, supportive care needs, and views toward supportive care of Asian LVAD patients and caregivers.

OBJECTIVES

We aimed to explore the experiences of multiethnic Asian LVAD patients and caregivers so as to identify their long-term challenges, supportive care needs, and views toward supportive care.

METHODS

Semistructured interviews with LVAD patients and caregivers were conducted based on the grounded theory approach. Participants were purposively recruited from the inpatient and outpatient settings of the National Heart Center Singapore.

RESULTS

A total of 30 patients and 11 caregivers participated. More than half of the participants were Chinese (patients 63%; caregivers 64%). Most patients (83%) were males, whereas most caregivers were females (91%). The median duration on support was 31 months and 46 months for patients and caregivers, respectively. The implantation of the LVAD was a significant milestone in their lives and caused long-term changes in multiple domains (physical, financial, social, psychoemotional, and spiritual). Experiencing permanent and recurrent losses over time was particularly challenging. Participants expressed the need for mutual support between patient and caregiver and connectedness with others and society at large. Participants desired holistic supportive care from their health care team.

CONCLUSION

Asian LVAD patients and caregivers experienced long-term challenges and had unique supportive care needs. Our findings have implications on the design of future interventions and supportive care models.

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

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

Staphylococcal driveline infections are the predominant type of left ventricular assist device associated infections in Singapore

BACKGROUND

Left ventricular assist device (LVAD) associated infections (LVADIs) have substantial morbidity and mortality. We aim to describe the incidence and epidemiology of LVADIs in an Asian cohort. This is currently not well studied.

METHODS

We conducted a retrospective review of 52 patients who underwent LVAD implantation from 1 May 2009-31 December 2014 in National Heart Centre Singapore. LVADIs were defined based on definitions proposed by the International Society for Heart and Lung Transplantation.

RESULTS

There were 39 males and 13 females. Seventy-three percent had Heartmate II LVAD implant while 27% received Heartware HVAD. Eighty-one percent were implanted as bridge to heart transplantation, 19% as destination therapy. Forty-five episodes of LVADIs occurred in 25 patients. Overall LVADI incidence was 47.5 cases per 100 patient-years. Driveline infections (58%) were the commonest type of LVADI. The commonest causative organisms were coagulase-negative staphylococci (33%), Staphylococcus aureus (31%) and Corynebacterium species (19%). Twelve percent of patients with LVADI required surgical debridement and one patient required pump exchange due to pump pocket infection. All-cause mortality was 13%.

CONCLUSIONS

The findings of our study add to the understanding and epidemiology of LVADIs, particularly in the Asian setting. This can contribute to the development of evidence based strategies to prevent and manage LVADIs.

Clinical Outcomes of Patients With the HeartMate II Left Ventricular Assist Device: A Single-center Experience From Japan

BACKGROUND

Left ventricular assist device (LVAD) therapy is the "gold standard" alternative therapy for patients with advanced heart failure. However, LVAD therapy is still uncommon in the Asia-Pacific region. Therefore, we aimed to elucidate the clinical outcomes of patients from Japan supported with the HeartMate II (HM-II) LVAD at our institution.

METHODS

Ninety-two patients (mean 44.3 ± 12.1 years, 68 men, average body mass index 1.65 ± 0.28 m²; 81 with nonischemic cardiomyopathy) who underwent HM-II implantation for bridge to transplantation (n = 91) or for destination therapy in a clinical study (n = 1) at the National Cerebral and Cardiovascular Center between April 2013 and October 2017 were enrolled in this analysis. Preoperatively, most patients (n = 73, 79%) had an INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profile of between level 2 and 4. Postoperatively, the average pump speed was 8602 ± 258 rpm and the hemodynamics were well compensated.

RESULTS

Adverse events consisted of 38 (41.3%) hemolysis, 30 (32.6%) major infection, 27 (29.3%) major bleeding (6 [6.5%] with gastrointestinal bleeding), and 18 (19.6%) neurologic dysfunction events. Eighteen patients underwent heart transplantation (HTx) after an average of 32.9 ± 8.9 months of VAD support, and overall survival at both 6 months and 3 years was 96.3%.

CONCLUSION

Clinical outcome among patients with HM-II at our institution is satisfactory for both survival and adverse events. The HM-II can provide effective hemodynamic support during the extremely long waiting period for HTx in Japan.

Ventricular assist devices and sleep-disordered breathing

Congestive heart failure is one of the leading causes of morbidity and mortality in the United States, and left ventricular assist devices have revolutionized treatment of end-stage heart failure. Given that sleep apnea results in significant morbidity in these patients with advanced heart failure, practicing sleep physicians need to have an understanding of left ventricular assist devices. In this review, we summarize what is known about ventricular assist devices as they relate to sleep medicine.