W.T. Caine

End-of-life decision making and implementation in recipients of a destination left ventricular assist device

BACKGROUND The use of left ventricular assist devices (LVADs) as destination therapy (DT) is increasing and has proven beneficial in prolonging survival and improving quality of life in select patients with end-stage heart failure. Nonetheless, end-of-life (EOL) issues are inevitable and how to approach them underreported. METHODS Our DT data registry was queried for eligible patients, defined as those individuals who actively participated in EOL decision making. The process from early EOL discussion to palliation and death was reviewed. We recorded the causes leading to EOL discussion, time from EOL decision to withdrawal and from withdrawal to death, and location. Primary caregivers were surveyed to qualify their experience and identify themes relevant to this process. RESULTS Between 1999 and 2009, 92 DT LVADs were implanted in 69 patients. Twenty patients qualified for inclusion (mean length of support: 833 days). A decrease in quality of life from new/worsening comorbidities usually prompted EOL discussion. Eleven patients died at home, 8 in the hospital and 1 in a nursing home. Time from EOL decision to LVAD withdrawal ranged from <1 day to 2 weeks and from withdrawal until death was <20 minutes in all cases. Palliative care was provided to all patients. Ongoing assistance from the healthcare team facilitated closure and ensured comfort at EOL. CONCLUSIONS With expanding indications and improved technology, more DT LVADs will be implanted and for longer durations, and more patients will face EOL issues. A multidisciplinary team approach with protocols involving DT patients and their families in EOL decision making allows for continuity of care and ensures dignity and comfort at EOL.

Differential impact on post‐transplant outcomes between pulsatile‐ and continuous‐flow left ventricular assist devices

Ventura PA, Alharethi R, Budge D, Reid BB, Horne BD, Mason NO, Stoker S, Caine WT, Rasmusson B, Doty J, Clayson SE, Kfoury AG. Differential impact on post‐transplant outcomes between pulsatile‐ and continuous‐flow left ventricular assist devices.
Clin Transplant 2011: 25: E390–E395.

Mixed cellular and antibody-mediated rejection in heart transplantation: In-depth pathologic and clinical observations

BACKGROUND Little is known about mixed cellular and antibody-mediated rejection (MR) in heart transplantation. It remains unclear whether cardiac MR has distinctive pathologic and clinical features beyond those of simultaneous cellular rejection (CR) and antibody-mediated rejection (AMR). In this study we systematically explore the pathologic and clinical characteristics of MR in heart transplantation. METHODS The UTAH Cardiac Transplant Program database was queried for transplant recipients who survived long enough to have at least one endomyocardial biopsy (EMB) between 1985 and 2014. Only EMBs with both CR and AMR scores documented were included. In addition to detailed pathologic analyses, we also examined the incidence and prevalence of MR, the likelihood to transition from and to MR, and mortality associated with MR. RESULTS Patients (n = 1,207) with a total of 28,484 EMBs met the study inclusion criteria. The overall prevalence of MR was 7.8% and it was nearly twice as frequent within the first year post-transplant. Mild MR was by far the most common occurrence and was typically preceded by an immune active state. When CR increased in severity, AMR tended to follow, but the reverse was not true. On pathology, individual features of CR and AMR were more easily separated in cases of mild MR, whereas they substantially overlapped in more severe cases. MR was associated with a significant cardiovascular death risk that was incremental with severity. CONCLUSIONS MR is not common, usually occurs early after transplant, and is associated with worse outcomes. MR reflects a complex interplay between cellular and humoral processes, which varies with rejection severity.

Comparing velour versus silicone interfaces at the driveline exit site of HeartMate II devices: infection rates, histopathology, and ultrastructural aspects.

BACKGROUND Driveline exit site (DLES) infection is a major complication of ventricular assist devices (VADs). Differences in the sheath material interfacing with exit site tissue appear to affect healing time and infection risk more than site hygiene, but the mechanistic basis for this is not clear. METHODS Health record data from Utah Artificial Heart Program patients with HeartMate II (HMII) devices implanted from 2008 to 2012 were retrospectively reviewed, with particular attention to interface type, incorporation (healing) time, and infections. Tissue samples from the DLES were collected at the time of VAD removal in a small subset. These samples were examined by routine histology and environmental scanning electron microscopy (ESEM). RESULTS Among 57 patients with sufficient data, 15 had velour interfaces and 42 had silicone. Indications for and duration of support were similar between the groups. The silicone group had shorter incorporation time (45 ±22 vs. 56 ±34 days, P=.17) and fewer DLES infections (20% vs. 1.7%, P=.026, for patient infections and 0.0340 vs. 0.166, P=.16, for infections per patient-year). Tissues from five patients, three with velour, were examined. Velour interfaces demonstrated more hyperkeratosis, hypergranulosis, and dermal inflammation. By ESEM, the silicone driveline tracts appeared relatively smooth and flat, whereas the velour interface samples were irregular with deep fissures and globular material adhering to the surface. CONCLUSIONS Using the silicone portion of the HMII driveline at the DLES was associated with fewer infections and a trend toward faster healing in this small retrospective series. Whether the intriguing microscopic differences directly account for this needs further study on a larger scale.

Predicting readmission risk shortly after admission for CABG surgery

Reducing preventable hospital readmissions after coronary artery bypass graft (CABG) surgery has become a national priority. Predictive models can be used to identify patients at high risk for readmission. However, the majority of the existing models are based on data available at discharge. We sought to develop a model to predict hospital readmission using data available soon after admission for isolated CABG surgery.

Reasons for, and Outcomes of Patients who were Referred for a Ventricular Assist Device but were Declined: The Recent Era Forgotten Ones

Ventricular assist devices (VADs) have a proven survival benefit in select patients with advanced heart failure, yet many patients considered for implantation are declined for various reasons. The outcome of these patients is obscure owing to their exclusion from recent VAD studies. We aim to compare the outcomes of patients who received a VAD to those who did not.

Reasons for Left Ventricular Assist Device Patient Denial: Insights into Possible Misconceptions about Mechanical Circulatory Support

Purpose Left ventricular assist devices (LVADs) are becoming a more common and effective therapy for patients with advanced heart failure. However, this technology is underutilized, and there is a general sense that many patients are referred too late, resulting in poor outcomes. The aim of this study was to determine why those patients referred for LVAD therapy who did not undergo LVAD implantation were found to be unsuitable candidates. Methods and Materials The UTAH Cardiac Transplant Program mechanical circulatory support databases were queried for all patients referred for an LVAD between 2006 and 2012. The patients were then stratified into those who received an LVAD and those who did not. For the patients who did not receive an LVAD, the reasons for referral rejection were collected and categorized. Results 604 patients were referred for an LVAD between our two centers of whom 338 (56%) did not receive an LVAD. For the rejected referral population, the average age was 59±14 years and 76% were male. The reasons for LVAD rejection are summarized below. Conclusions In our experience, more than half of patients referred for an LVAD did not receive this therapy. A substantial percent of these patients were declined on the basis of being too sick at the time of evaluation, suggesting that many patients are referred too late. More efforts to educate the referral community about the benefits of a timely referral are needed to improve outcomes and cost-efficiency of LVADs. Reason for RejectionPatients (%)Too Sick81 (24.0)- Renal or Liver Disease17 (5.0)- Acute Critical Illness16 (4.7)- Comorbidities14 (4.1)- Pulmonary Disease11 (3.3)- Multi-Organ Dysfunction7 (2.1)- GI Disorders4 (1.2)- Infection4 (1.2)- Cancer4 (1.2)- Old Age3 (0.9)- Ventricular Arrythmias1 (0.3)Medically Managed80 (23.7)Patient Declined64 (18.9)LVAD as Backup Only32 (9.5)Went to Heart Transplant32 (9.5)Lack of Funding22 (6.5)LVAD Not Needed9 (2.7)Lack of Social Support8 (2.4)Non-Compliance5(1.5)Other5 (1.5)

Mitral valve replacement and tricuspid valve repair through a transseptal approach for double-valve endocarditis.

The transseptal approach is a useful technique for patients who have valvular disease involving both the mitral and tricuspid valves. This incision provides excellent exposure for addressing pathology on both valves and has the added advantage of extension up onto the dome of the left atrium if additional exposure required. This exposure provides the ability to perform the full range of reparative operations or valve replacement with minimal distortion of the heart.