Canadian Cardiovascular Society 2023 Guidelines on the Fitness to Drive

Cardiovascular conditions are among the most frequent causes of impairment to drive, because they might induce unpredictable mental state alterations via diverse mechanisms like myocardial ischemia, cardiac arrhythmias, and vascular dysfunction. Accordingly, health professionals are often asked to assess patients' fitness to drive (FTD). The Canadian Cardiovascular Society previously published FTD guidelines in 2003-2004; herein, we present updated FTD guidelines. Because there are no randomized trials on FTD, observational studies were used to estimate the risk of driving impairment in each situation, and recommendations made on the basis of Canadian Cardiovascular Society Risk of Harm formula. More restrictive recommendations were made for commercial drivers, who spend longer average times behind the wheel, use larger vehicles, and might transport a larger number of passengers. We provide guidance for individuals with: (1) active coronary artery disease; (2) various forms of valvular heart disease; (3) heart failure, heart transplant, and left ventricular assist device situations; (4) arrhythmia syndromes; (5) implantable devices; (6) syncope history; and (7) congenital heart disease. We suggest appropriate waiting times after cardiac interventions or acute illnesses before driving resumption. When short-term driving cessation is recommended, recommendations are on the basis of expert consensus rather than the Risk of Harm formula because risk elevation is expected to be transient. These recommendations, although not a substitute for clinical judgement or governmental regulations, provide specialists, primary care providers, and allied health professionals with a comprehensive list of a wide range of cardiac conditions, with guidance provided on the basis of the level of risk of impairment, along with recommendations about ability to drive and the suggested duration of restrictions.

Three-month outcomes after the implantation of two HeartMate 3 devices in total artificial heart configuration

BACKGROUND

Total artificial heart (TAH) implantation is a rarely performed procedure. Contrarily, left ventricular assist device (VAD) implantation is rather common in many centers. As transplantation is quantitatively limited cardiac replacement with artificial hearts is a viable alternative in the treatment of severe biventricular heart failure. An alternative to TAH is the implantation of two VADs in a TAH configuration. We hereby present the first multi-center study on 3-months outcomes of patients treated by cardiectomy and placement of two HeartMate 3s in a TAH configuration.

METHODS

We retrospectively investigated a cohort of 15 patients that underwent HM3-TAH-implantation at three international institutions. Follow-up was 3 months after implantation. Baseline, intra- and postoperative parameters as well as survival data and adverse events were collected.

RESULTS

A total of 1089 days on HM3-TAH were observed. Thirty-day survival after HM3-TAH implantation was 53% (8/15) and three month survival was 40% (6/15). The longest duration on device was 274 days. Causes of death were multi-organ failure, sepsis, and neurological adverse events. No technical complications were documented. Two patients remained on the device. Four patients (26%) were successfully bridged to transplantation.

CONCLUSIONS

The implantation of two HeartMate 3s in a TAH configuration is a last resort and off-label concept in cases of extreme biventricular heart failure. In a diligently selected patient cohort, HM3-TAH implantation is a feasible method to increase the chance of survival in a severely ill patient cohort and successfully bridge patients to heart transplantation that would otherwise have died.

It's not only the pump: Assessment of human factors of wearable components and user experience of patients with left ventricular assist devices

BACKGROUND

Despite design improvements in left ventricular assist devices (LVADs) over the past decade, limitations of external, wearable VAD components affect patient quality of life and safety. The aim of this study was to describe both user experience and human factor issues of 2 contemporary LVADs.

METHODS

This single-center, cross-sectional study included LVAD outpatients who were at least 3 months after implantation. Before developing the 16-item survey, a systematic literature review and 2-round Delphi method involving 9 VAD clinicians were used to select items in 6 domains: power supply, emergency situations, wearability, mobility, and freedom to travel, user modifications, lifestyle, and home adaptations.

RESULTS

Fifty-eight patients (61.6 ± 11.6 years, 13.8% female, HeartMate 3 (HM3)/HVAD: n = 39/19) completed the one-time survey after median of 853 days on device: 10.3% reported problems changing power supply, 12.7% unintentional driveline disconnection (HM3: 5.6% vs HVAD: 26.3%, p = 0.041). Against the recommendation 74.1% sleep with battery-support (HM3: 88.9% vs HVAD: 44.4%, p = 0.001). About 65.3% criticized the carry bag weight/size (HM3: 71.4% vs HVAD: 50.0%, p = 0.035), thus 24.1% wear an own carrying-system, 42.1% modified their wearables, 38.9% their clothing, and 65.3% their home to cope with life on LVAD support. Mobility is reduced due to limited wearability: 18.9% went abroad (only 3.7% by plane) and 40.0% use less public transport than before implantation (the older the less: r = -0.37, p = 0.013).

CONCLUSIONS

HVAD and HM3 wearables still show a variety of human factors issues and potential for improved user experience. User-centered design and incorporation of patient feedback may increase user satisfaction, and patient safety.

Flying after left ventricular assist device implantation

Literature on the air travel activities of patients supported by permanent mechanical assist devices is rare. To the best of our knowledge, no air travel guidelines or fitness prerequisites exist on whether and when ventricular assist device (VAD) patients are allowed to travel by plane after device implantation. In this study, we evaluated the topic of air travel after VAD implantation. This working group aimed to produce a report on air travel passengers supported by VADs, regarding their fitness to fly. Fifty left ventricular assist device (LVAD) patients were surveyed in a worldwide multicenter study. The single survey was performed with a multimethod design, including interviews conducted face-to-face, online, and on phone. Out of 50 patients, 97% described their traveling by aircraft as perfect and uneventful during the flight. Eighty-five percent of the study participants consulted their medical practitioner before the flight. No patient reported the occurrence of a severe condition associated with flying. LVAD alarms, especially low flow alarms, did not occur in any of the devices. Thirty-five percent of the surveyed patients, however, stated a major problem pertaining to the security check procedures at the airport. The results of this study suggest that commercial air travel is safe for stable patients on permanent VAD support and traveling can be resumed securely after VAD implantation. Conscientious preparation by packing necessary devices, fluids, medications, and careful preparation for the airport security check is recommended.

Left Ventricular Assist Devices 101: Shared Care for General Cardiologists and Primary Care

Ambulatory patients with a left ventricular assist device (LVAD) are increasing in number, and so is their life expectancy. Thus, there is an increasing need for care of these patients by non-LVAD specialists, such as providers in the emergency department, urgent care centers, community-based hospitals, outpatient clinics, etc. Non-LVAD specialists will increasingly come across LVAD patients and should be equipped with the knowledge and skills to provide initial assessment and management for these complex patients. These encounters may be for LVAD-related or unrelated issues. However, there are limited data and guidelines to assist non-LVAD specialists in caring for these complex patients. The aim of our review, targeting primary care providers (both inpatient and outpatient), general cardiologists, and other providers is to describe the current status of durable LVAD therapy in adults, patient selection, management strategies, complications and to summarize current outcome data.

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.

Human Factors and User Experience Issues with Ventricular Assist Device Wearable Components: A Systematic Review

Ventricular Assist Devices (VADs) provide continuous mechanical circulatory support during in- and out-of-hospital care. However, limitations of the external wearable components influence patient quality of life. There is insufficient understanding of the issues with such components that combines a holistic viewpoint from both human factors and user (including patient and caregiver) experience perspectives. This paper comprehensively details the issues with VAD wearable systems and proposes a way for human-centered design to bridge the gap, addressing such issues synergistically. Through the review the authors investigated: the user issues caused by wearable components of VADs, and how human factors issues correlate to the VAD user experience. A Boolean search ("ventricular assist" AND "human factors" AND "experience") for peer-reviewed studies published between 2008 and 2018 returned 338 titles, with 35 relevant studies selected using a PRISMA process for inclusion in cross-study analysis and synthesis. This paper provides design recommendations for the issues found in the literature. Four key focus areas to inform the future design of VAD wearable components were identified-'Power Supply', 'Wearability and Travel Freedom', 'The Female Experience' and 'Intuitive Handling'. Using design to drive innovation could result in VAD wearable components which better meet or exceed users' quality of life goals.

Inpatient Cardiac Rehabilitation of LVAD Patients-Updated Recommendations from the Working Group of the German Society for Prevention and Rehabilitation of Cardiovascular Diseases

Cardiac rehabilitation physicians are faced to an increasing number of heart failure patients supported by left ventricular assist devices (LVAD). Many of these patients have complex medical issues and prolonged hospitalizations and therefore need special cardiac rehabilitation strategies including psychological, social, and educational support which are actually poorly implemented.Cardiac rehabilitation with clear guidance and more evidence should be considered as an essential component of the patient care plan especially regarding the increasing number of destination patients and their long-term follow-up.In this article the working group for postimplant treatment and rehabilitation of LVAD patients of the German Society for Prevention and Rehabilitation of Cardiovascular Diseases has summarized and updated the recommendations for the cardiac rehabilitation of LVAD patients considering the latest literature.

Artificial Organs 2018: A Year in Review

In this Editor's Review, articles published in 2018 are organized by category and summarized. We provide a brief reflection of the research and progress in artificial organs intended to advance and better human life while providing insight for continued application of these technologies and methods. Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level." Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. Peer-reviewed special issues this year included contributions from the 13th International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion edited by Dr. Akif Undar, and the 25th Congress of the International Society for Mechanical Circulatory Support edited by Dr. Marvin Slepian. Additionally, many editorials highlighted the worldwide survival differences in hemodialysis and perspectives on mechanical circulatory support and stem cell therapies for cardiac support. We take this time also to express our gratitude to our authors for offering their work to this journal. We offer our very special thanks to our reviewers who give so generously of time and expertise to review, critique, and especially provide meaningful suggestions to the author's work whether eventually accepted or rejected. Without these excellent and dedicated reviewers the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, John Wiley & Sons for their expert attention and support in the production and marketing of Artificial Organs. We look forward to reporting further advances in the coming years.