Tuvia Ben Gal

Comparison of self-care behaviors of heart failure patients in 15 countries worldwide

OBJECTIVE Clinicians worldwide seek to educate and support heart failure patients to engage in self-care. We aimed to describe self-care behaviors of patients from 15 countries across three continents. METHODS Data on self-care were pooled from 5964 heart failure patients from the United States, Europe, Australasia and South America. Data on self-care were collected with the Self-care of Heart Failure Index or the European Heart Failure Self-care Behavior Scale. RESULTS In all the samples, most patients reported taking their medications as prescribed but exercise and weight monitoring were low. In 14 of the 22 samples, more than 50% of the patients reported low exercise levels. In 16 samples, less than half of the patients weighed themselves regularly, with large differences among the countries. Self-care with regard to receiving an annual flu shot and following a low sodium diet varied most across the countries. CONCLUSION Self-care behaviors are sub-optimal in heart failure patients and need to be improved worldwide. PRACTICE IMPLICATIONS Interventions that focus on specific self-care behaviors may be more effective than general educational programs. Changes in some health care systems and national policies are needed to support patients with heart failure to increase their self-care behavior.

Organization of heart failure management in European Society of Cardiology member countries: Survey of the Heart Failure Association of the European Society of Cardiology in collaboration with the Heart Failure National Societies/Working Groups

The aim of this document was to obtain a real‐life contemporary analysis of the demographics and heart failure (HF) statistics, as well as the organization and major activities of the Heart Failure National Societies (HFNS) in European Society of Cardiology (ESC) member countries.

Learning Self-care After Left Ventricular Assist Device Implantation

The number of heart failure (HF) patients living with a left ventricular assist device (LVAD) as destination therapy is increasing. Successful long-term LVAD support includes a high degree of self-care by the patient and their caregiver, and also requires long-term support from a multidisciplinary team. All three components of self-care deserve special attention once an HF patient receives an LVAD, including activities regarding self-care maintenance (activities related both to the device and lifestyle), self-care monitoring (e.g., monitoring for complications or distress), and self-care management (e.g., handling alarms or coping with living with the device). For patients to perform optimal self-care once they are discharged, they need optimal education that focuses on knowledge and skills through a collaborative, adult learning approach.

Levosimendan beyond inotropy and acute heart failure: Evidence of pleiotropic effects on the heart and other organs: An expert panel position paper

Levosimendan is a positive inotrope with vasodilating properties (inodilator) indicated for decompensated heart failure (HF) patients with low cardiac output. Accumulated evidence supports several pleiotropic effects of levosimendan beyond inotropy, the heart and decompensated HF. Those effects are not readily explained by cardiac function enhancement and seem to be related to additional properties of the drug such as anti-inflammatory, anti-oxidative and anti-apoptotic ones. Mechanistic and proof-of-concept studies are still required to clarify the underlying mechanisms involved, while properly designed clinical trials are warranted to translate preclinical or early-phase clinical data into more robust clinical evidence. The present position paper, derived by a panel of 35 experts in the field of cardiology, cardiac anesthesiology, intensive care medicine, cardiac physiology, and cardiovascular pharmacology from 22 European countries, compiles the existing evidence on the pleiotropic effects of levosimendan, identifies potential novel areas of clinical application and defines the corresponding gaps in evidence and the required research efforts to address those gaps.

Self-care and communication issues at the end of life of recipients of a left-ventricular assist device as destination therapy.

Purpose of reviewThe purpose of this review is to provide an overview of self- care and communication issues at the end of life of patients with left-ventricular assist devices (LVADs) for destination therapy, based on recent research on end-of-life communication in other diseases. Recent findingsFor many patients with advanced heart failure, LVADs as destination therapy improve survival and quality of life. However, LVADs can be associated with complications, new comorbidities or worsening of previous conditions, resulting in decreased quality of life and limited prognosis, raising the need for planning palliative and end-of-life care. Open communication addressing the consequences of the LVAD implantation for daily life and the future (including advance directives) is advised in different stages of the treatment, involving a multidisciplinary team taking care of these complex patients and their caregivers. SummaryHealthcare professionals treating patients before and after LVAD implantation need to take an active role in end-of-life discussions and be able to communicate information regarding expected complications, quality of life and prognosis to the patients and caregivers. Research is needed addressing optimal ways and timing of communication with LVAD patients and families

Coronary air embolism treated by bubble aspiration

We describe a case of coronary air embolism following cardiac catheterization, with all the signs and symptoms of an acute coronary event. Thanks to the rapid and effective aspiration of the air bubble from the distal artery, blood flow was restored and the clinical picture was resolved. Cathet. Cardiovasc. Intervent. 49:452–454, 2000.

Increasing exercise capacity and quality of life of patients with heart failure through Wii gaming : The rationale, design and methodology of the HF-Wii study; A multicentre randomized controlled trial

Exercise is known to be beneficial for patients with heart failure (HF), and these patients should therefore be routinely advised to exercise and to be or to become physically active. Despite the beneficial effects of exercise such as improved functional capacity and favourable clinical outcomes, the level of daily physical activity in most patients with HF is low. Exergaming may be a promising new approach to increase the physical activity of patients with HF at home. The aim of this study is to determine the effectiveness of the structured introduction and access to a Wii game computer in patients with HF to improve exercise capacity and level of daily physical activity, to decrease healthcare resource use, and to improve self‐care and health‐related quality of life.

Exercise programs for LVAD supported patients: A snapshot from the ESC affiliated countries

BACKGROUND To contribute to the protocol development of exercise training in LVAD supported patients by reviewing the exercise programs for those patients in the ESC affiliated countries. METHODS A subset of data from 77 (26 countries) LVAD implanting centers that participated in the Extra-HF survey (170 centers) was analyzed. RESULTS Of the 77 LVAD implanting centers, 45 (58%) reported to have a functioning exercise training program (ETP) for LVAD patients. In 21 (47%) of the 45 ETP programs in LVAD implanting centers, patients begin their ETP during their in-hospital post-operative recovery period. Most centers (71%) have an early post-discharge program for their patients, and 24% of the centers offer a long-term maintenance program. The professionals involved in the ETPs are mainly physiotherapists (73%), psychologists, cardiac rehab nurses (22%), or cardiologists specialized in rehabilitation (22%). Not all programs include the treating cardiologist or surgeons. Most of the ETPs (84%) include aerobic endurance training, mostly cycling (73%), or walking (62%) at low intensity intervals. Some programs apply resistance training (47%), respiratory muscle training (55%), or balance training (44%). Reasons for the absence of ETPs are referral of patients to another center (14 centers) and lack of resources (11 centers). CONCLUSION There is a great variance in ETPs in LVAD implanting centers. Not all the implanting centers have an ETP, and those that do have adopted a local protocol. Clear guidance on ETP supplied by LVAD implanting centers to LVAD supported patients and more evidence for optimal modalities are needed.

Angiogenic Imbalance and Residual Myocardial Injury in Recovered Peripartum Cardiomyopathy PatientsCLINICAL PERSPECTIVE

Background—Recent studies suggest that angiogenic imbalance during pregnancy may lead to acute peripartum cardiomyopathy (PPCM). We propose that angiogenic imbalance and residual cardiac dysfunction may exist even after recovery from PPCM. Methods and Results—Twenty-nine women at least 12 months after presentation with PPCM, who exhibited recovery of left ventricular (LV) ejection fraction (≥50%), were included in the study (mean age 35±6 years, LV ejection fraction 61.0±3.9%). The number of circulating endothelial progenitor cells (EPCs) and plasma levels of proangiogenic vascular endothelial growth factor and of soluble vascular endothelial growth factor receptor Flt1 (sFlt1) were measured. All patients underwent comprehensive cardiac function assessment, including tissue Doppler imaging and 2-dimensional (2D) strain echocardiography. All measurements were compared with healthy controls. Patients with a history of PPCM have significantly higher sFlt1 concentrations (median [25th–75th percentile]; 149.57, [63.14–177.89] versus 20.29, [15.00–53.89] pg/mL, P<0.001) and significantly decreased vascular endothelial growth factor/sFlt1 ratio (P=0.012) compared with controls, with a trend toward lower concentration of circulating CD34+/KDR+ levels. In addition, patients with PPCM had lower early velocities E′ septal (9.9±2.1 versus 11.0±1.5 cm/s, P=0.02), with a significantly lower systolic velocity S′ septal (7.6±1.2 versus 8.5±1.2 cm/s, P=0.003) by tissue Doppler imaging. Significantly lower LV global longitudinal (−19.1±3.3 versus −22.7±2.2%, P<0.001) and apical circumferential 2D strain (−16.6±4.9 versus −21.2±7.9, P=0.02) were present in patients with PPCM compared with controls. Conclusions—Higher concentration of sFlt1 with concomitant decreased circulating endothelial progenitor cell levels along with inappropriate attenuated vascular endothelial growth factor levels may imply an angiogenic imbalance that exists even after recovery and may thus predispose to PPCM. In addition, tissue Doppler imaging and 2D strain were able to identify residual myocardial injury in post-PPCM women with apparent recovery of LV systolic function. Both angiogenic imbalance and residual myocardial injury may play an important role in the recurrence of LV dysfunction during subsequent pregnancies.

Early Physical Rehabilitation after Continuous Flow Left Ventricular Assist Device Implantation: Suggested Protocol and a Pilot Study

Background: Left Ventricular Assist Device (LVAD) implantation is an optional therapy for patients with end stage heart failure. Physical rehabilitation after an LVAD implantation is beneficial for the patients recovery. A detailed protocol for and our experience with a very early post LVAD implantation individualized physical rehabilitation is presented. Method: Twelve patients who underwent LVAD implantations between April 2010 and April 2011 were included in the study. As soon as the patients were able to walk by themselves (7-10 days post-op), they started aerobic exercise on a treadmill and on the Nustep: combining hand and leg aerobic exercise. Exercise was started at low intensity and for short intervals. The target was to increase intensity and duration. Progress was based on Both Subjective (Borg Scale) and objective (6 Minutes Walk Test: 6MWT) parameters. Results: Walking time and speed on the treadmill was increased from two 2-4 minutes intervals to one continuous 10 minutes exercise. The time and intensity on the Nustep increased from two intervals of 1-3 minutes to one continuous 16 minutes exercise and from 10-20 watts to 30 watts, respectively. An improvement was seen in the 6MWT from baseline to hospital discharge: 131 ± 91 meters to 262 ± 84 meters respectively (p<0.01) and from discharge to the first LVAD clinic visit: 251 ± 80 meters to 307 ± 88 m meters respectively (p<0.01). All patients reported improvement in carrying the 2-2.5 Kg of battery weight (from difficult to tolerable). Discussion: A very early stage rehabilitation program after LVAD implantation is feasible and may improve the functional capacity and the ability to carry the LVAD batteries of the LVAD supported patient. Larger studies are needed to determine the optimal time to start rehabilitation program post LVAD implantation.