Jane MacIver

Mechanical circulatory support as a bridge to transplant candidacy

Abstract  Introduction:  The use of mechanical circulatory support (MCS) in nontransplant eligible candidates remains controversial. Our decision to offer MCS for nontransplant candidates has led to their reevaluation after a period of left ventricular assist device (LVAD) support. Methods: From 2001 to September 2009, we had 37 patients who received an implantable LVAD, 22 (59%) were not deemed to be transplant eligible at the time of LVAD insertion (bridge to candidacy, BTC group). Results: Fifteen (41%) patients were considered transplant eligible (bridge to transplant, BTT group) at the time of device insertion and received a HeartMate XVE (n = 7), HeartMate 2 (n = 7), or a Novacor LVAS (n = 1). In the BTC group, patients received the HeartMate XVE device (n = 11), HeartMate 2 (n = 5), or the Novacor LVAS (n = 6). The primary criterion for transplant ineligibility was refractory pulmonary hypertension (PH) in 18 patients, 3 patients did not meet our body mass index criteria (>35 kg/m2), and 2 patients were dialysis‐dependent. Six (27%) BTC patients died on support. Overall, 16/22 patients (73%) were subsequently listed for transplantation, with one listed for combined heart–lung due to refractory PH. Twelve patients (75%) underwent successful heart transplantation. Three patients died during their transplant. Overall posttransplant survival at one year shows lower survival in the BTC group compared to the BTT group (67% vs. 100%, p = 0.05). At two years and three years the survival was lower, but not statistically different (BTC vs. BTT: 67% vs. 90% and 64% vs. 87%, respectively, p = NS). Conclusions: MCS can successfully convert a large proportion of transplant‐ineligible patients into acceptable candidates. (J Card Surg 2011;26:542‐547)

Mechanical circulatory support with the ABIOMED BVS 5000: the Toronto General Hospital experience.

BACKGROUND Acute hemodynamic collapse resulting in cardiogenic shock and impending end-organ failure is usually associated with certain death. The introduction of short-term mechanical circulatory support (MCS) devices offers potential therapy to these critically ill patients. The BVS 5000 device (ABIOMED Inc, USA) is widely used in the United States, but rarely in Canada, where device reimbursement remains a barrier. OBJECTIVE To present the Toronto General Hospitals (Toronto, Ontario) initial five-year experience with this device to highlight the indications for use, common complications and overall success rates. METHODS AND RESULTS The institutional MCS database from 2001 to 2006 was reviewed, and 18 patients who received 30 devices in a variety of configurations were identified. The most common support configuration consisted of biventricular support (n=12), followed by isolated left ventricular support (n=4) and isolated right ventricular support in two recipients of an implantable long-term left ventricular assist device. Overall survival to device explant or transplant was 55% (n=10), of which five (50%) were successfully discharged from the hospital. The overall survival from device implant to hospital discharge was 28% (five of 18). The most common cause of death was multisystem organ failure. CONCLUSIONS MCS with the ABIOMED BVS 5000 can successfully resuscitate critically ill patients; however, earlier institution of this device would avoid irreversible end-organ injury, and lead to higher rates of device explant and hospital discharge. Short-term MCS devices should be available in all cardiac surgical centres in Canada to permit stabilization and evaluation of the acutely ill cardiac patient and subsequent management in a heart transplant facility.

Readmissions Following Implantation of a Continuous-Flow Left Ventricular Assist Device.

The objective of this study is to review and analyze readmission data for patients who received a continuous flow left ventricular assist device (LVAD).

Lost in Translation Examining Patient and Physician Perceptions of Implantable Cardioverter-Defibrillator Deactivation Discussions

Since its introduction into mainstream clinical practice in the 1980s, the implantable cardioverter-defibrillator (ICD) has become the treatment of choice for potentially life-threatening ventricular arrhythmias.1 ICDs are recommended by the American College of Cardiology/American Heart Association/Heart Rhythm Society in select patients as primary prevention to lower the risk of sudden cardiac death.2,3 Estimates of ICD prevalence in Canada number >110000 people with an annual growth rate of 4%, which corresponds to an equivalent prevalence of >700000 in the United States.4 ICDs work by sensing ventricular tachycardia and ventricular fibrillation and restoring the underlying rhythm via antitachy pacing (ventricular tachycardia) or through delivering an electric shock across the myocardium (ventricular tachycardia/ventricular fibrillation).5 Despite their proficiency in preventing sudden cardiac death, ICDs cannot remedy the underlying cardiac abnormality, hence patients ultimately develop progressive heart failure, a trajectory the ICD cannot improve. As their condition worsens, patients with heart failure may develop hypoxia, sepsis, and electrolyte imbalances, which can serve to further potentiate arrhythmia, subsequently increasing shock frequency.6 ICD shocks may in this setting become undesirable. ICDs have been unequivocally shown to prolong life. However, in some patients they do so at the expense of painful shocks that diminish patients’ self-perceived quality of life.7 Approximately 30% of ICD patients experience shocks in the minutes before death.8 Some patients have likened these electric shocks to being kicked in the chest by a horse.9 In an investigation comparing quality of life measures in ICD patients and those administered a pharmacological intervention, both physical and psychological functioning were diminished in the ICD group, especially in those who received >5 shocks.6 Furthermore, the generally adverse and unpredictable timing of an ICD shock was found to be a source of psychological distress.10 The number of years …

The prognostic significance of frailty compared to peak oxygen consumption and B-type natriuretic peptide in patients with advanced heart failure

Frailty assessment has become an integral part of the evaluation of potential candidates for heart transplantation and ventricular assist device (HTx/VAD). The impact of frailty, as a heart failure risk factor or to identify those who will derive the greatest benefit with HTx/VAD remains unclear. The aim of this study was to evaluate the independent prognostic relevance of frailty assessment from peak oxygen consumption (peak VO2) or B‐type natriuretic peptide (BNP) on mortality in patients referred for advanced heart failure therapies. Frailty was measured using modified Fried frailty criteria. In 201 consecutive patients, during a median follow‐up of 17.5 months (IQR 11‐29.2), there were 25 (12.4%) deaths. One‐year survival was 100%, 94%, and 78% in nonfrail, prefrail, and frail patients, respectively (log rank P = .0001). Frailty was associated with a twofold increase risk of death (HR 2.01, P < .0001, 95% CI 1.42‐2.84). When adjusted for BNP or peak VO2, frailty was not associated with a significant risk of all‐cause death. However, when peak VO2 is stratified into two categories (≥12 mL/kg/min vs <12 mL/kg/min), frailty was associated with increased mortality in patients with a lower peak VO2 (HR 1.72, P = .006).

Patient perceptions of implantable cardioverter-defibrillator deactivation discussions: A qualitative study.

Background: There is a class I recommendation for implantable cardioverter-defibrillator deactivation discussions to occur between physicians and heart failure patients. Few studies have reported the patient’s perspective on the timing of implantable cardioverter-defibrillator deactivation discussions. Aim: To determine patient awareness, preferences and timing of implantable cardioverter-defibrillator deactivation discussions. Design: Grounded theory was used to collect and analyze interview data from 25 heart failure patients with an implantable cardioverter-defibrillator. Setting and participants: Patients with an implantable cardioverter-defibrillator, from the Heart Function Clinic at University Health Network (Toronto, Canada). Results: The sample (n = 25) was predominately male (76%) with an average age of 62 years. Patients identified three stages where they felt implantable cardioverter-defibrillator deactivation should be discussed: (1) prior to implantation, (2) with any significant deterioration but while they were of sound mind to engage in and communicate their preferences and (3) at end of life, where patients wished further review of their previously established preferences and decisions about implantable cardioverter-defibrillator deactivation. Most patients (n = 17, 68%) said they would consider deactivation, six (24%) were undecided and two (8%) were adamant they would never turn it off. Conclusion: The patient preferences identified in this study support the need to include information on implantable cardioverter-defibrillator deactivation at implant, with change in clinical status and within broader discussions about end-of-life treatment preferences. Using this process to help patients determine and communicate their implantable cardioverter-defibrillator deactivation preferences may reduce the number of patients experiencing distressing implantable cardioverter-defibrillator shocks at end of life.

Barriers to goals of care discussions with hospitalized patients with advanced heart failure: feasibility and performance of a novel questionnaire

Good end‐of‐life communication and decision‐making are important to patients with advanced heart failure (HF) and their families, but their needs remain unmet. In this pilot study, we describe the feasibility and performance of a novel questionnaire aimed at identifying barriers and solutions to improve communication and decision‐making about goals of care for hospitalized patients with advanced HF.

Measuring quality of life in advanced heart failure.

Purpose of review Patients with Stage D heart failure can benefit from palliative care consultation to help them manage unpleasant symptoms and improve quality of life. Although guidelines describe how to manage symptoms, very little direction is provided on how to evaluate the effectiveness of those interventions. Recent findings Numerous studies have used the measurement of symptoms, emotional distress, functional capacity and quality of life to evaluate the effectiveness of interventions in heart failure. There is limited evidence on the use of these instruments in heart failure palliative care. Four studies were identified that evaluate the effectiveness of palliative care consultation for patients with advanced heart failure. All four studies measured symptom severity, emotional distress, and quality of life. The application of appropriate instruments is discussed. Suggestions for scores that should trigger palliative care consultation are identified. Summary The routine administration of standardized instruments to measure symptom severity and quality of life may improve the assessment and management of patients with Stage D heart failure. Ongoing discussion and research is needed to determine if these instruments are the best tools to use with heart failure palliative care patients.

Long-term use of left ventricular assist devices: a report on clinical outcomes

Background The literature examining clinical outcomes and readmissions during extended (> 1 yr) left ventricular assist device (LVAD) support is scarce, particularly in the era of continuous-flow LVADs. Methods We completed a retrospective cohort study on consecutive LVAD patients from June 2006 to March 2015, focusing on those who received more than 1 year of total LVAD support time. Demographic characteristics, clinical outcomes and readmissions were analyzed using standard statistical methods. All readmissions were categorized as per the Interagency Registry for Mechanically Assisted Circulatory Support 2015 guidelines. Results Of the 103 patients who received LVADs during the study period, 37 received LVAD support for more than 1 year, with 18 receiving support for more than 2 years. Average support time was 786 ± 381 days, with total support time reaching 80 patient-years. During a median follow-up of 2 years, 27 patients died, with 1-year conditional survival of 74%. Median freedom from first readmission was 106 days (range 1–603 d), with an average length of stay of 6 days. Readmissions resulted in an average of 41 ± 76 days in hospital per patient. Reasons for readmission were major infection (24%), major bleeding (19%) and device malfunction/thrombus (13%). There were a total of 112 procedures completed during the readmissions, with 60% of procedures being done in 13% (n = 5) of patients. Conclusion Continuous-flow LVADs provide excellent long-term survival. The present study describes marked differences in reasons for readmissions between the general LVAD population and those supported for more than 1 year. Prolonged LVAD support resulted in decreased susceptibility to major bleeds and increased susceptibility to infection.