The Incidence, Risk, and Consequences of Atrial Arrhythmias in Patients with Continuous-Flow Left Ventricular Assist Devices

Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review

Left ventricular assist devices (LVADs) are increasingly common across the heart failure population. Right ventricular failure (RVF) is a feared complication that can occur in the early post-operative phase or during the outpatient follow-up. Multiple tools are available to the clinician to carefully estimate the individual risk of developing RVF after LVAD implantation. This review will provide a comprehensive overview of available tools for RVF prognostication, including patient-specific and right ventricle (RV)-specific echocardiographic and hemodynamic parameters, to provide guidance in patient selection during LVAD candidacy. We also offer a multidisciplinary approach to the management of early RVF, including indications and management of right ventricular assist devices in this setting to provide tools that help managing the failing RV.

Role of the mitral valve in left ventricular assist device pathophysiology

Functional mitral regurgitation (MR) in the setting of heart failure results from progressive dilatation of the left ventricle (LV) and mitral annulus. This leads to leaflet tethering with posterior displacement. Contrary to common assumptions, MR often does not resolve with LVAD decompression of the LV alone. The negative impact of significant (moderate-severe) mitral regurgitation in the LVAD setting is becoming better recognized in terms of its harmful effect on right heart function, pulmonary vascular resistance and hospital readmissions. However, controversies remain regarding the threshold for intervention and management. At present, there are no consensus indications for the repair of significant mitral regurgitation at the time of LVAD implantation due to the conflicting data regarding potential adverse effects of MR on clinical outcomes. In this review, we summarize the current understanding of MR pathophysiology in patients supported with LVAD and potential future management strategies.

Right heart failure after left ventricular assist device: From mechanisms to treatments

Left ventricular assist device (LVAD) therapy is a lifesaving option for patients with medical therapy-refractory advanced heart failure. Depending on the definition, 5-44% of people supported with an LVAD develop right heart failure (RHF), which is associated with worse outcomes. The mechanisms related to RHF include patient, surgical, and hemodynamic factors. Despite significant progress in understanding the roles of these factors and improvements in surgical techniques and LVAD technology, this complication is still a substantial cause of morbidity and mortality among LVAD patients. Additionally, specific medical therapies for this complication still are lacking, leaving cardiac transplantation or supportive management as the only options for LVAD patients who develop RHF. While significant effort has been made to create algorithms aimed at stratifying risk for RHF in patients undergoing LVAD implantation, the predictive value of these algorithms has been limited, especially when attempts at external validation have been undertaken. Perhaps one of the reasons for poor performance in external validation is related to differing definitions of RHF in external cohorts. Additionally, most research in this field has focused on RHF occurring in the early phase (i.e., ≤1 month) post LVAD implantation. However, there is emerging recognition of late-onset RHF (i.e., > 1 month post-surgery) as a significant cause of morbidity and mortality. Late-onset RHF, which likely has a unique physiology and pathogenic mechanisms, remains poorly characterized. In this review of the literature, we will describe the unique right ventricular physiology and changes elicited by LVADs that might cause both early- and late-onset RHF. Finally, we will analyze the currently available treatments for RHF, including mechanical circulatory support options and medical therapies.

Effect of levosimendan infusion prior to left ventricular assist device implantation on right ventricular failure

Objective

Investigate the safety and efficacy of preoperative levosimendan in patients undergoing left ventricular assist device (LVAD) implantation.

Methods

Consecutive patients who received LVADs (HeartMate-2, 3, HVAD) in a single tertiary medical center (2012–2018). INTERMACS profile 1 patients were excluded. The primary outcome was post-LVAD right ventricular failure (RVF) and inhospital mortality rates. The secondary outcomes included other clinical, echocardiographic and hemodynamic parameters at follow-up.

Results

Final cohort consisted of 62 patients (40[65%] in the levosimendan group and 22[35%] in the no-levosimendan group). Post-operative RVF rate and inotrope or ventilation support time were similar in the levosimendan and no-levosimendan groups (7.5% vs. 13.6%; P = 0.43, median of 51 vs. 72 h; P = 0.41 and 24 vs. 27 h; P = 0.19, respectively). Length of hospitalization, both total and in the intensive care unit, was not statistically significant (median days of 13 vs. 16; P = 0.34, and 3 vs. 4; P = 0.44, respectively). Post-operative laboratory and echocardiographic parameters and in-hospital complication rate did not differ between the groups, despite worse baseline clinical parameters in the Levosimendan group. There was no significant difference in the in-hospital and long term mortality rate (2.5% vs. 4.5%; P > 0.999 and 10% vs. 27.3% respectively; P = 0.64).

Conclusions

Levosimendan infusion prior to LVAD implantation was safe and associated with comparable results without significant improved post-operative outcomes, including RVF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01915-6.

Point-of-Care Ultrasound in the Evaluation of Patients with Left Ventricular Assist Devices at the Emergency Department

BACKGROUND

Left ventricular assist devices (LVADs) can be used as a bridging therapy for myocardial recovery or cardiac transplant, as well as a destination therapy for long-term support in patients with advanced heart failure. Patients with LVADs can present to the emergency department (ED) for acute deterioration and emergency physicians (EPs) must be equipped with the necessary knowledge and skill to treat this unique population.

OBJECTIVE

This review describes the role of point-of-care ultrasound (POCUS) in the evaluation of patients with LVADs and illustrates how EPs can incorporate POCUS into the evaluation of these patients in the ED.

DISCUSSION

The clinical applications for which POCUS may be useful in patients with LVADs include hypotension or shock, dyspnea, cardiac failure, dysrhythmia, syncope, and cardiac arrest. The normal features of POCUS in patients with LVADs and the features of POCUS associated with diseased states are presented.

CONCLUSIONS

Patients with LVADs have altered anatomy and physiology. Therefore, an understanding of key modifications to standard POCUS views is necessary so that EPs can use POCUS effectively in their evaluation of these patients.

Pre-operative atrial fibrillation and early right ventricular failure after left ventricular assist device implantation: a systematic review and meta-analysis

BACKGROUND

Right ventricular failure (RVF) remains a major cause of morbidity and mortality after left ventricular assist device (LVAD). Atrial fibrillation (AF) is known for its deleterious effects on cardiac function and hemodynamics. The association of pre-operative AF with the risk of early post-LVAD RVF has not been well described.

METHOD

A comprehensive literature search was performed through April, 9 2021. Cohort studies comparing the risk of post-operative RVF and/or need for right ventricular assist device (RVAD) after LVAD in patients with or without AF were included. Pooled odds ratio (OR) with 95% confidence intervals (CI) and I² statistic were calculated using the random-effects model.

RESULTS

Six studies were included in the analysis. Post-operative RVF was reported in 5 studies (1,841 patients) and RVAD use was reported in 4 studies (1,355 patients). There is a non-significant trend toward a higher risk of post-operative RVF in the AF group (pooled OR=1.25, 95%CI=0.99-1.58). No significant association between AF and RVAD use is noted (pooled OR=1.17, 95%CI=0.82-1.66).

CONCLUSIONS

Pre-operative AF is not significantly associated with higher risks of post-operative RVF and RVAD use after LVAD implantation, although the trend toward higher post-operative RVF is observed in patients with pre-operative AF. Additional research using a larger study population is warranted to better understand the association of pre-operative AF and the development of post-LVAD RVF.

Clinical implications of late-onset right ventricular failure after implantation of a continuous-flow left ventricular assist device as bridge to transplantation

OBJECTIVES

The development of late-onset right ventricular failure (LoRVF) that occurs months after a continuous-flow left ventricular assist device (LVAD) is implanted is a clinical problem that warrants investigation. Our goal was to study the incidence, clinical manifestations and prognosis of LoRVF in a population of patients who received an LVAD as bridge to transplantation.

METHODS

Data were analysed from 97 consecutive patients who received an LVAD as bridge to transplantation and underwent a right heart catheterization at least 3 months after receiving an LVAD implantation. LoRVF was defined if both haemodynamic criteria of a central venous pressure >16 mmHg and a cardiac index <2.3 l/min/m2 were present. Clinical and echocardiographic variables, hospitalizations for heart failure and survival were compared between patients with and without LoRVF.

RESULTS

LoRVF was diagnosed in 13% of patients after a median time of 11 months. Patients with LoRVF presented preoperative worse right ventricular (RV) dilatation and severe tricuspid regurgitation. LORVF was also associated with postoperative RV dilatation, moderate to severe tricuspid regurgitation and lower tricuspid annular plane systolic excursion. LoRVF resulted in increased brain natriuretic peptide levels and the need for diuretics, lower haemoglobin levels and a higher rate of atrial fibrillation and gastrointestinal bleeding. The rate of hospitalizations for heart failure in patients with LoRVF was 46%, and 15% required an urgent transplantation due to refractory RV failure. LoRVF decreased global survival and survival free from hospitalizations for heart failure (P < 0.0001).

CONCLUSIONS

LoRVF after the implantation of an LVAD as bridge to transplantation is associated with higher morbidity and lower survival. The results suggest that the routine use of a right heart catheterization and transthoracic echocardiography may contribute to an early diagnosis before further severe complications due to refractory RV failure might occur.

ID NUMBER OF THE IRB APPROVAL

AZ-2019-521 on 10 July 2019.

Right ventricular failure after left ventricular assist device implantation: a review of the literature

Right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation remains a major complication which may significantly impair patient outcome. The genesis of RVF is, however, multifactorial, and the mechanisms underlying such a condition have not been fully elucidated, making its prevention challenging and the course not always predictable. Although preoperative risks factors can be associated with RV impairment, the physiologic changes after the LV support, can still hamper the function of the RV. Current medical treatment options are limited and sometimes, patients with a severe post-LVAD RVF may be unresponsive to pharmacological therapy and require more aggressive treatment, such as temporary RV support. We retrieved 11 publications which we assessed and divided in groups based on the RV support [extracorporeal membrane oxygenation (ECMO), right ventricular assist device (RVAD), TandemHeart with ProtekDuo cannula]. The current review comprehensively summarizes the main studies of the literature with particular attention to the RV physiology and its changes after the LVAD implantation, the predictors and prognostic score as well as the different modalities of temporary mechanical cardio-circulatory support, and its effects on patient prognosis for RVF in such a setting. In addition, it provides a decision making of the pre-, intra and post-operative management in high- and moderate- risk patients.

Atrial arrhythmias in patients with left ventricular assist devices

PURPOSE OF REVIEW

Atrial arrhythmias commonly occur in patients with advanced heart failure with reduced ejection fraction (HFrEF) who require left ventricular assist devices (LVADs) implantation. This review summarizes the current literature regarding the incidence, prevalence, and predictors of atrial arrhythmias in LVAD patients and its impact on the clinical outcomes. Moreover, we review the mechanisms and management strategies of atrial arrhythmias in this population.

RECENT FINDINGS

Atrial arrhythmias including atrial fibrillation, atrial flutter, and atrial tachycardia are highly prevalent in patients with advanced HFrEF before or after the LVAD implantation. Atrial arrhythmias have a significant impact on overall clinical outcome including survival, heart failure hospitalization, quality of life, thromboembolic events and resource utilization. Atrial fibrillation and other atrial arrhythmias frequently coexist in this population. In patients with atrial arrhythmias and LVAD, anticoagulation and cardiovascular implantable electronic devices should be closely monitored and managed to prevent thromboembolic events or inappropriate shocks. Rhythm and rate control strategies are comparable regarding overall clinical outcomes in this population. LVADs induce favorable atrial remodeling in patients with HFrEF.

SUMMARY

Atrial arrhythmias are highly common in LVAD patients and have significant impact on overall clinical outcomes. Further studies are needed to determine optimal management and prevention of atrial arrhythmias in LVAD population.

Off-label use of pulmonary vasodilators after left ventricular assist device implantation: Calling in the evidence

Left ventricular assist devices (LVAD) are increasingly implanted in advanced heart failure patients to improve survival and quality of life either as a bridge to transplant, bridge to recovery or as destination therapy. LVAD therapy is often accompanied by a profound lowering of pulmonary artery pressure due to mechanical unloading of the left ventricle. Persistent pulmonary hypertension (PH) after LVAD implantation increases the risk of right ventricular failure (RVF). In this context pulmonary vasodilators have been implemented: a) as a strategy to reduce afterload and wean patients with RVF from inotropes in the early postoperative period, b) as long-term therapy aiming to optimize right heart hemodynamics and prevent late RVF and c) in order to lower persistently elevated pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) after LVAD and enable candidacy for heart transplantation. However, considerable uncertainty exists regarding the risks and benefits of these strategies and practices vary widely among institutions. This article provides an overview of the available evidence and existing recommendations regarding the use of pulmonary vasodilators in LVAD recipients.

Predictors of Physical Capacity 6 Months After Implantation of a Full Magnetically Levitated Left Ventricular Assist Device: An Analysis From the ELEVATE Registry

BACKGROUND

In patients with a continuous-flow left ventricular assist device, preimplant predictors of poor physical performance are not well-described. We aimed to identify predictors of inability to walk more than 300 m on 6-minute walk test (6MWT) 6 months after HeartMate 3 implantation.

METHODS AND RESULTS

Using data from the European Registry of Patients Implanted With a Full Magnetically Levitated LVAD, patients with available 6MWT at 6 months after implantation were included (N = 194) and grouped according to 6MWT distance (6MWD) of >300 m (n = 150) or 6MWD of <300 m (n = 44). Patients walking <300 m were older (60 ± 10 vs 52 ± 12 years; P < .001), more often New York Heart Association functional class IV (63% vs 42%; P = .03), and more often had type 2 diabetes (43% vs 17%; P < .001) at implantation. Atrial fibrillation was seen in 57% in those with a 6MWT of <300 m vs 31% in those walking longer (P < .002). Further, hemoglobin and estimated glomerular filtration rate was lower in those walking <300 m (both P < .01). In multivariable regression analysis, independent predictors of a 6MWD of <300 m were: atrial fibrillation (odds ratio [OR], 3.22; 95% confidence interval [CI], 1.12-8.67), older age (OR for 10-year increment, 2.81; 95% CI, 1.55-5.07), New York Heart Association functional class IV (OR, 3.37; 95% CI, 1.27-8.98), and Interagency Registry for Mechanically Assisted Circulatory Support profile 1 or 2 (OR, 6.53; 95% CI, 1.92-22.19).

CONCLUSIONS

Six months after HeartMate 3 implantation, 77% of patients walked >300 meters in 6 minutes. Apart from age and measures of heart failure severity, atrial fibrillation at implantation is an independent predictor of low 6MWD at 6 months after implantation.

Insight into Atrial Fibrillation in LVAD Patients: From Clinical Implications to Prognosis

The use of left ventricular assist devices (LVADs), whether for destination therapy or bridge to transplantation, has gained increasing validation in recent years in patients with advanced heart failure. Arrhythmias can be the most challenging variables in the management of such patients but the main attention has always been focused on ventricular arrhythmias given the detrimental impact on mortality. Nevertheless, atrial fibrillation (AF) is the most common rhythm disorder associated with advanced heart failure and may therefore characterize the LVADs' pre- and postimplantation periods. Indeed, the consequences of AF in the population suffering from standard heart failure may require a more comprehensive evaluation in the presence of or in sight of an LVAD, making the AF clinical management in these patients potentially complex. Several studies have been based on this subject with different and often conflicting results, leaving many questions unresolved. The purpose of this review is to summarize the main pieces of evidence about the clinical impact of AF in LVAD patients, underlining the main implications in terms of hemodynamics, thromboembolic risk, bleeding and prognosis. Therapeutic considerations about the clinical management of these patients are also made according to the latest evidence.

Ventricular arrhythmias following continuous-flow left ventricular assist device implantation: A systematic review

Ventricular arrhythmias (VA) are not uncommon after continuous-flow left ventricular assist device (CF-LVAD) implantation. In this systematic review, we sought to identify the patterns of VA that occurred following CF-LVAD implantation and evaluate their outcomes. An electronic search was performed to identify all articles reporting the development of VA following CF-LVAD implantation. VA was defined as any episode of ventricular fibrillation (VF) or sustained (>30 seconds) ventricular tachycardia (VT). Eleven studies were pooled for the analysis that included 393 CF-LVAD patients with VA. The mean patient age was 57 years [95%CI: 54; 61] and 82% [95%CI: 73; 88] were male. Overall, 37% [95%CI: 19; 60] of patients experienced a new onset VA after CF-LVAD implantation, while 60% [95%CI: 51; 69] of patients had a prior history of VA. Overall, 88% of patients [95%CI: 78; 94] were supported on HeartMate II CF-LVAD, 6% [95%CI: 3; 14] on HeartWare HVAD, and 6% [95%CI: 2; 13] on other CF-LVADs. VA was symptomatic in 47% [95%CI: 28; 68] of patients and in 50% [95%CI: 37; 52], early VA (<30 days from CF-LVAD) was observed. The 30-day mortality rate was 7% [95%CI: 5; 11]. Mean follow-up was 22.9 months [95%CI: 4.8; 40.8], during which 27% [95%CI: 17; 39] of patients underwent heart transplantation. In conclusion, approximately a third of patients had new VA following CF-LVAD placement. VA in CF-LVAD patients is often symptomatic, necessitates treatment, and carries a worse prognosis.

Computational Simulation of Cardiac Function and Blood Flow in the Circulatory System under Continuous Flow Left Ventricular Assist Device Support during Atrial Fibrillation

Prevalence of atrial fibrillation (AF) is high in heart failure patients supported by a continuous flow left ventricular assist device (CF-LVAD); however, the long term effects remain unclear. In this study, a computational model simulating effects of AF on cardiac function and blood flow for heart failure and CF-LVAD support is presented. The computational model describes left and right heart, systemic and pulmonary circulations and cerebral circulation, and utilises patient-derived RR interval series for normal sinus rhythm (SR). Moreover, AF was simulated using patient-derived unimodal and bimodal distributed RR interval series and patient specific left ventricular systolic functions. The cardiovascular system model simulated clinically-observed haemodynamic outcomes under CF-LVAD support during AF, such as reduced right ventricular ejection fraction and elevated systolic pulmonary arterial pressure. Moreover, relatively high aortic peak pressures and middle arterial peak flow rates during AF with bimodal RR interval distribution, reduced to similar levels as during normal SR and AF with unimodal RR interval distribution under CF-LVAD support. The simulation results suggest that factors such as distribution of RR intervals and systolic left ventricular function may influence haemodynamic outcome of CF-LVAD support during AF.

Medical Management of Left Ventricular Assist Device Patients: A Practical Guide for the Nonexpert Clinician

Left ventricular assist devices (LVADs) provide short- or long-term circulatory support to improve survival and reduce morbidity in selected patients with advanced heart failure. LVADs are being used increasingly and now have expanded indications. Health care providers across specialties will therefore not only encounter LVAD patients but play an integral role in their care. To accomplish that, they need to understand the elements of LVAD function, physiology and clinical use. This article provides a concise overview of the medical management of LVAD patients for nonexpert clinicians. Our presentation includes the basics of LVAD physiology, design, and operation, patient selection and assessment, medical management, adverse event identification and management, multidisciplinary care, and management of special circumstances, such as noncardiac surgery, cardiac arrest, and end-of-life care. The clinical examination of LVAD patients is unique in terms of blood pressure and heart rate assessment, LVAD "hum" auscultation, driveline and insertion site inspection, and device parameter recording. Important potential device-related adverse events include stroke, gastrointestinal bleeding, hematologic disorders, device infection, LVAD dysfunction, arrhythmias, and heart failure. Special considerations include the approach to the unconscious or pulseless patient, noncardiac surgery, and palliative care. An understanding of the principles presented in this paper will enable the nonexpert clinician to be effective in collaborating with an LVAD center in the assessment, medical management, and follow-up of LVAD patients. Future opportunities and challenges include the improvement of device designs, greater application of minimally invasive surgical implantation techniques, and management of health economics in cost-constrained systems like those of Canada and many other jurisdictions.

Device Therapy and Arrhythmia Management in Left Ventricular Assist Device Recipients: A Scientific Statement From the American Heart Association

Left ventricular assist devices (LVADs) are an increasingly used strategy for the management of patients with advanced heart failure with reduced ejection fraction. Although these devices effectively improve survival, atrial and ventricular arrhythmias are common, predispose these patients to additional risk, and complicate patient management. However, there is no consensus on best practices for the medical management of these arrhythmias or on the optimal timing for procedural interventions in patients with refractory arrhythmias. Although the vast majority of these patients have preexisting cardiovascular implantable electronic devices or cardiac resynchronization therapy, given the natural history of heart failure, it is common practice to maintain cardiovascular implantable electronic device detection and therapies after LVAD implantation. Available data, however, are conflicting on the efficacy of and optimal device programming after LVAD implantation. Therefore, the primary objective of this scientific statement is to review the available evidence and to provide guidance on the management of atrial and ventricular arrhythmias in this unique patient population, as well as procedural interventions and cardiovascular implantable electronic device and cardiac resynchronization therapy programming strategies, on the basis of a comprehensive literature review by electrophysiologists, heart failure cardiologists, cardiac surgeons, and cardiovascular nurse specialists with expertise in managing these patients. The structure and design of commercially available LVADs are briefly reviewed, as well as clinical indications for device implantation. The relevant physiological effects of long-term exposure to continuous-flow circulatory support are highlighted, as well as the mechanisms and clinical significance of arrhythmias in the setting of LVAD support.

Approach to Complications of Ventricular Assist Devices: A Clinical Review for the Emergency Provider

BACKGROUND

Heart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted ventricular assist devices (VADs).

OBJECTIVE

This review provides an evidence-based summary of the current data for the evaluation and management of implanted VAD complications in an emergency department context.

DISCUSSION

With a prevalence of >5.8 million individuals and >550,000 new cases diagnosed each year, heart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted VADs. As the prevalence of patients with VADs continues to grow, they will sporadically present to the emergency department, regardless of whether the facility is a designated VAD center. As a result, all emergency physicians must be familiar with the basic principles of VAD function, as well as the diagnosis and initial management of VAD-related complications. In this review, we address these topics, with a focus on contemporary third-generation continuous flow VADs. This review will help supplement the critical care skills of emergency physicians in managing this complex patient population.

CONCLUSIONS

The cornerstone of managing the unstable VAD patient is rapid initiation of high-quality supportive care and recognition of device-related complications, as well as the identification and use of specialist VAD teams and other resources for support. Emergency physicians must understand VADs so that they may optimally manage these complex patients.

Usefulness of Tricuspid Annular Diameter to Predict Late Right Sided Heart Failure in Patients With Left Ventricular Assist Device

Although late-onset right-sided heart failure is recognized as a clinical problem in the treatment of patients with left ventricular assist devices (LVADs), the mechanism and predictors are unknown. Tricuspid valve (TV) deformation leads to the restriction of the leaflet motion and decreased coaptation, resulting in a functional tricuspid regurgitation that may act as a surrogate marker of late right-sided heart failure. This study aimed to investigate the association of preoperative TV deformation (annulus dilatation and leaflet tethering) with late right-sided heart failure development after continuous-flow LVAD implantation. The study cohort consisted of 274 patients who underwent 2-dimensional echocardiography before LVAD implantation. TV annulus diameter and tethering distance were measured in an apical 4-chamber view. Late right-sided heart failure was defined as right-sided heart failure requiring readmission and medical and/or surgical treatment after initial LVAD implantation. During a mean follow-up of 25.1 ± 19.0 months after LVAD implantation, late right-sided heart failure occurred in 33 patients (12.0%). Multivariate Cox proportional hazard analysis demonstrated that TV annulus diameter (hazard ratio 1.221 per 1 mm, p <0.001) was significantly associated with late right-sided heart failure development, whereas leaflet tethering distance was not. The best cut-off value of the TV annular diameter was 41 mm (area under the curve 0.787). Kaplan-Meier analysis showed that patients with dilated TV annulus (TV annular diameter ≥41 mm) exhibited a significantly higher late right-sided heart failure occurrence than those without TV annular enlargement (log-rank p <0.001). In conclusion, preoperative TV annulus diameter, but not leaflet tethering distance, predicted the occurrence of late right-sided heart failure after LVAD implantation.

Postoperative atrial fibrillation is associated with increased morbidity and resource utilization after left ventricular assist device placement

BACKGROUND

Postoperative atrial fibrillation (POAF) is a known risk factor for morbidity and mortality after cardiac surgery but has not been investigated in the left ventricular assist device (LVAD) population. We hypothesize that POAF will increase morbidity and resource utilization after LVAD placement.

METHODS

Records were extracted for all patients in a regional database who underwent continuous-flow LVAD placement (n = 1064, 2009-2017). Patients without a history of atrial fibrillation (n = 689) were stratified by POAF for univariate analysis. Multivariable regression models calculated the risk-adjusted association of arrhythmias on outcomes and resource utilization.

RESULTS

The incidence of new-onset POAF was 17.6%, and patients who developed POAF were older and more likely to have moderate/severe mitral regurgitation, a history of stroke, and concomitant tricuspid surgery. After risk adjustment, POAF was not associated with operative mortality or stroke but was associated with major morbidity (odds ratio [OR] 2.5 P = .0004), prolonged ventilation (OR 2.7, P < .0001), unplanned right ventricular assist device (OR 2.9, P = .01), and a trend toward renal failure (OR 2.0, P = .06). In addition, POAF was associated with greater risk-adjusted resource utilization, including discharge to a facility (OR 2.2, P = .007), an additional 4.9 postoperative days (P = .02), and 88 hours in the intensive care unit (P = .01).

CONCLUSIONS

POAF was associated with increased major morbidity, possibly from worsening right heart failure leading to increased renal failure and unplanned right ventricular assist device placement. This led to patients with POAF having longer intensive care unit and hospital stays and more frequent discharges to a facility.

Chronic outpatient management of patients with a left ventricular assist device

The use of mechanical circulatory support (MCS) as treatment for advanced heart failure (HF) has grown exponentially over the past 15 years. The continuous flow left ventricular assist device (CF-LVAD) has become the most used form of MCS in advanced HF, especially since approval of use as destination therapy (DT) and with the lack of organ availability. Long-term survival has improved and diligent outpatient management is thus particularly critical to achieve optimal outcomes. This review will discuss outpatient management strategies for patients with HF and a left ventricular assist device (LVAD).