Martha Abshire

Functional status in left ventricular assist device-supported patients: a literature review.

The prevalence of advanced heart failure (HF) is increasing because of the aging population and improvements in HF management strategies. Left ventricular assist device (LVAD) technology and management continue to advance rapidly, and it is anticipated that the number of LVAD implants will increase. LVADs have been demonstrated to extend life and improve outcomes in patients with advanced HF. The purpose of this article is to review and synthesize the evidence on impact of LVAD therapy on functional status. Significant functional gains were demonstrated in patients supported by LVAD throughout the 1st year, with most improvement in distance walked and peak oxygen consumption demonstrated in the 1st 6 months. Interventions to enhance exercise performance have had inconsistent effects on functional status. Poor exercise performance was associated with increased risk of adverse events. Functional status improved with LVAD therapy, although performance remained substantially reduced compared with age-adjusted norms. There is tremendous need to enhance our understanding of factors influencing functional outcomes in this high-risk population.

Cognition and adherence are self-management factors predicting the quality of life of adults living with a left ventricular assist device

BACKGROUND There is no empirical study about the context and influence of self-management (SM) factors on quality of life (QOL) among adults with left ventricular assist device (LVADs). The purpose of this study was to close this knowledge gap by: (1) differentiating select SM factors (e.g., cognition) and overall QOL based on LVAD implant durations; (2) examining the relationships among SM factors and QOL variables; and (3) identifying which SM factors predict QOL. METHODS An observational study was employed including 87 LVAD patients, ages 20 to 80 years, with mean implant durations of 18.5 ± 15.1 months. Patients completed 1 demographic questionnaire and 6 measures of SM factors (cognition-general and executive function, LVAD self-efficacy, care dependency and adherence) and QOL. Data were analyzed with descriptive and inferential statistical procedures. RESULTS There was no significant difference in SM factors and overall QOL by LVAD implant durations. SM factors, including cognitive function, LVAD self-efficacy, and adherence, correlated positively with QOL (r = 0.35 to 0.48, p < 0.05), but LVAD care dependency correlated negatively with QOL (r = -0.21, p < 0.05). The general and executive function of cognition and LVAD adherence were significant predictors of QOL. CONCLUSIONS The data inferred that higher level of cognitive function is associated with higher self-efficacy, adherence and greater QOL, whereas lower care dependency is associated with greater QOL. Higher cognitive function and adherence to the LVAD care regimen predicted better QOL outcome. Further research is needed to elucidate the mechanism by which SM factors influence QOL in adults with long-term LVADs.

Nutritional Interventions in Heart Failure: A Systematic Review of the Literature

BACKGROUND Heart failure (HF) is a major health care burden and there is a growing need to develop strategies to maintain health and sustain quality of life in persons with HF. The purpose of this review is to critically appraise the components of nutrition interventions and to establish an evidence base for future advances in HF nutrition research and practice. METHODS AND RESULTS Cinahl, Pubmed, and Embase were searched to identify articles published from 2005 to 2015. A total of 17 randomized controlled trials were included in this review. Results were divided into 2 categories of nutrition-related interventions: (1) educational and (2) prescriptive. Educational interventions improved patient outcomes such as adherence to dietary restriction in urine sodium levels and self-reported diet recall. Educational and prescriptive interventions resulted in decreased readmission rates and patient deterioration. Adherence measurement was subjective in many studies. Evidence showed that a normal-sodium diet and 1-liter fluid restriction along with high diuretic dosing enhanced B-type natriuretic peptide, aldosterone, tumor necrosis factor α, and interleukin-6 markers. CONCLUSIONS Educational nutrition interventions positively affect patient clinical outcomes. Although clinical practice guidelines support a low-sodium diet and fluid restriction, research findings have revealed that a low-sodium diet may be harmful. Future research should examine the role of macronutrients, food quality, and energy balance in HF nutrition.

Heart Failure Rehospitalization and Delayed Decision Making: The Impact of Self-care and Depression

Background: Rehospitalization soon after discharge can be distressing for persons with heart failure (HF) and places a heavy burden on the healthcare system. Objective: We investigated and explored the association of self-care decision making variables with (1) rehospitalization within 30 days of discharge and (2) delay in seeking medical assistance (delayed decision making). Methods: A cross-sectional, explanatory sequential mixed methods design (quan > qual) was used to survey 127 hospitalized HF patients and interview 15 of these participants to explain their survey responses. The survey assessed rehospitalization within 30 days of discharge, delayed decision making, HF self-care, and psychosocial factors influencing self-care. Results: The likelihood of delaying the decision to be hospitalized was more than 5 times higher among those with high depressive symptoms (odds ratio, 5.33; 95% confidence interval, 2.14–13.28). Those who delayed going to the hospital were uncertain about their prognosis and did not feel their symptoms were urgent. The likelihood of being rehospitalized within 30 days was more than doubled among those with high depressive symptoms (OR, 2.31; 95% confidence interval, 1.01–5.31). Those who were rehospitalized within 30 days were less likely to consult healthcare professionals in their decision making and wanted immediate relief from their symptoms. Conclusions: We recommend a patient-centered approach to help HF patients identify and adequately self-manage symptoms. The strong association between high depressive symptoms and rehospitalization within 30 days as well as delayed decision making highlights the critical need for clinicians to carefully assess and address depression among HF patients.

Go with the flow: progress in mechanical circulatory support.

Heart failure (HF) affects over 5 million Americans and approximately 50,000 HF patients die each year.1 Advanced HF (i.e., New York Heart Association class 3-4) typically has a prognosis of less than two years and the limited treatment options include: palliative medical management, heart transplant or mechanical circulatory support (MCS) using left ventricular assist device (LVAD).2 The vast majority receive primarily palliative medical management. Approximately 2,200 of these individuals are on the waiting list for heart transplant though limited availability of donor organs contributes to a low number of heart transplants.3 MCS technology is advancing and it is estimated that between 40,000 -200,000 HF patients may benefit from the support of a LVAD.4 In 2012, 2,113 LVADs were placed, and it is anticipated that insertion rates will continue to increase annually.5 Cardiovascular nurses need to be informed leaders in this rapidly developing field. LVADs fall into a class of MCS devices that assume the responsibility of circulation in place of the failing heart. The LVAD is a pump that is attached to the left ventricle to support the failing heart. To power the device, a driveline extends from the pump through the abdomen and emerges percutaneously to connect to an external controller device. This controller attaches to either an AC power source or batteries. The LVAD does not have a role in the electrical firing of the heart, as do devices like automatic internal cardioverter defibrillators. LVADs are unique from other MCS because they are designed for management in the home setting. Early LVADs were used exclusively for patients who needed a heart transplant but were decompensating and unable to wait for the donor organ. This use is commonly referred to as “bridge to transplant”. In 2001, a landmark study, the Randomized Evaluation of Mechanical Assistance of Congestive Heart Failure Trial published findings that supported use of LVADs as destination therapy.2 Destination therapy means that a patients’ HF will be treated with LVAD and there is not an expectation that the patient will become eligible for transplant. In addition to bridge to transplant and destination therapy, some LVADs are inserted in acute refractory HF and these patients are “bridged to recovery”, meaning the device is removed after native pump function has been restored. LVAD technology has advanced along with the increased indications for use. Early LVADs were pulsatile devices that mimicked the pooling and pumping of blood in the ventricle. Non-pulsatile, continuous flow devices have replaced pulsatile devices which are no longer manufactured due to a significantly higher occurrence of stroke.6 In 2010, the first continuous flow device was approved for destination therapy.7 The good news is that patients do benefit from LVADs. Although patients are frequently decompensated prior to insertion and the surgery to insert the device requires a sternotomy, it has been demonstrated that functional status and quality of life improve significantly with LVAD regardless of bridge to transplant or destination therapy indication.8-12 As the technology and management techniques have advanced, so has survival in this population with three month survival for LVAD patients recently reported to be 89%.5 In February 2013, the International Society for Heart and Lung Transplantation Guidelines for MCS were released.13 This was the first comprehensive effort to synthesize research into practice guidelines for the selection and management of LVAD patients. These guidelines have clear implications for cardiovascular nursing practice. Selection of advanced HF patients for LVAD and timing of insertion surgery has been much debated in the literature. The guidelines discourage LVAD surgery for patients with neurologic compromise, permanent dialysis needs, multi-organ failure or sepsis.13 Common co-morbidities such as diabetes, pulmonary hypertension, previously treated cancers, obesity and hypoperfusion-related organ dysfunction are not contraindications for LVAD, but do merit close evaluation. In addition, though bioprosthetic valves are not a contraindication for LVAD, mechanical valves should be replaced at the time of LVAD insertion. The guidelines further encourage sobriety both from illicit drugs and alcohol and suggest educating patients regarding smoking cessation prior to surgery. A critical component of selecting eligible patients is identifying and educating the primary caregiver alongside the patient. LVAD is not recommended for a patient without an engaged caregiver. In an effort to support decision-making in this area of rapidly advancing science and clinical practice, the Interagency Registry for Mechanically Assisted Circulatory Support data has been used to establish clinical profiles of MCS users and examine associated outcomes.14 The guidelines establish a systematic approach to guide patients and their families in decision-making regarding destination therapy versus a more palliative approach in the face of transplant ineligibility. Addressing palliative medical care options, advanced directives, and end of life issues are recommended as part of the pre-operative evaluation. It may be appropriate to involve an ethics board in some instances. Pre-op education should take a multi-disciplinary approach with informed consent to include common expectations and complications.13 For example, LVAD patients often experience frequent and lengthy hospitalizations. A recent study found that LVAD patients at one center spent 13% of their time in the first year after implant in the hospital, with an average of three readmissions of about 14 days each.12 It is essential that patients and their families understand their options for management and potential implications of their decision. Finally, outpatient management of LVAD patients is the ultimate goal of destination therapy. To ensure adequacy of the home environment, the guidelines suggest a home visit by a trained provider. Intrinsic to the success of LVAD home management is the contribution of the patients caregiver. This person is identified and educated prior to surgery and in many cases signs a ‘contract’ of agreement to provide care. The caregiver is educated alongside the patient on all aspects of care including managing the batteries, alarms, dressing the driveline, pharmaceutical management, nutrition and mobility. While nursing care of modern LVADs is highly specialized, there is important information that all cardiovascular nurses should know about LVADs (see Table 1). Cardiac ICU and telemetry nurses in academic, transplant centers typically undergo extensive training and annual competencies including hands-on skills demonstrations. There is evidence supporting the use of multi-disciplinary teams which often involve surgeons, other physicians, LVAD engineer, LVAD nurse/Nurse Practitioner, pharmacist, nutritionist, physical and occupational therapy. Nurses often are key advocates and care coordinators for LVAD patients. Table 2 lists recommendations for learning more about LVADs. Table 1 Information that every cardiovascular nurse should know about LVADs Table 2 Recommendations for learning more about LVADs The future direction of LVAD technology is to develop batteries allowing for fully implantable devices. It is anticipated that advances in technology and evidence-based inpatient and outpatient management strategies will result in reductions in adverse outcomes related to infection as well as additional improvements in quality of life and functional status. As LVADs become more commonly used, particularly as destination therapy, we can expect to see an increase in the number of LVAD patients and a proliferation of LVAD programs. Nurses have an opportunity to be at the forefront of this rapidly progressing area of advanced HF care.

Family caregivers: Important but often poorly understood

Internationally, there are growing numbers of unpaid caregivers, with increasing numbers leaving paid work to provide care (National Academies of Sciences & Medicine 2016). Nomenclature for this role includes family, informal and unpaid caregivers as well as terms such as medical visit companion. This terminology in itself fails to encompass the importance of the role given the critical contribution to healthcare This article is protected by copyright. All rights reserved.

Decision Making Among Persons Living With Heart Failure.

Background:Persons with heart failure (HF) are required to make decisions on a daily basis related to their declining health and make urgent decisions during acute illness exacerbations. However, little is known about the types of decisions patients make. Objective:The aims of this study were to critically evaluate the current quantitative literature related to decision making among persons with HF and identify research gaps in HF decision-making research. Methods:A systematic search of literature about decisions persons with HF make was conducted using PubMed, CINAHL, and PsychINFO databases. The following inclusion criteria were used: sample composed of at least 50% HF participants, concrete decisions were made, and a quantitative study design was used. Two authors performed title, abstract, and full-text reviews independently to identify eligible articles. Results:Twelve quantitative articles were included. Study samples were predominately older, white, male, and married. Two-thirds of the articles focused on decisions related to the end-of-life topics (ie, resuscitation decisions, advanced care planning). The other one-third focused on decisions about care seeking, participant’s involvement in treatment decisions during their last clinic visit, and self-care behaviors. Conclusions:Within the HF literature, the term decision is often ill-defined or not defined. Limitations in methodological rigor limit definitive conclusions about HF decision making. Future studies should consider strengthening study rigor and examining other decision topics such as inclusion of family in making decisions as HF progresses. Research rigorously examining HF decision making is needed to develop interventions to support persons with HF.