Life Beyond Heart Failure-What Are the Long-Term Challenges, Supportive Care Needs, and Views Toward Supportive Care of Multiethnic Asian Patients With Left Ventricular Assist Device and Their Caregivers?

CONTEXT: Challenges experienced by patients with the left ventricular assist device (LVAD) and their caregivers during the early period after LVAD implantation are well documented. However, little is known about long-term challenges, supportive care needs, and views toward supportive care of Asian LVAD patients and caregivers. OBJECTIVES: We aimed to explore the experiences of multiethnic Asian LVAD patients and caregivers so as to identify their long-term challenges, supportive care needs, and views toward supportive care. METHODS: Semistructured interviews with LVAD patients and caregivers were conducted based on the grounded theory approach. Participants were purposively recruited from the inpatient and outpatient settings of the National Heart Center Singapore. RESULTS: A total of 30 patients and 11 caregivers participated. More than half of the participants were Chinese (patients 63%; caregivers 64%). Most patients (83%) were males, whereas most caregivers were females (91%). The median duration on support was 31 months and 46 months for patients and caregivers, respectively. The implantation of the LVAD was a significant milestone in their lives and caused long-term changes in multiple domains (physical, financial, social, psychoemotional, and spiritual). Experiencing permanent and recurrent losses over time was particularly challenging. Participants expressed the need for mutual support between patient and caregiver and connectedness with others and society at large. Participants desired holistic supportive care from their health care team. CONCLUSION: Asian LVAD patients and caregivers experienced long-term challenges and had unique supportive care needs. Our findings have implications on the design of future interventions and supportive care models.

Staphylococcal driveline infections are the predominant type of left ventricular assist device associated infections in Singapore.

BACKGROUND: Left ventricular assist device (LVAD) associated infections (LVADIs) have substantial morbidity and mortality. We aim to describe the incidence and epidemiology of LVADIs in an Asian cohort. This is currently not well studied. METHODS: We conducted a retrospective review of 52 patients who underwent LVAD implantation from 1 May 2009-31 December 2014 in National Heart Centre Singapore. LVADIs were defined based on definitions proposed by the International Society for Heart and Lung Transplantation. RESULTS: There were 39 males and 13 females. Seventy-three percent had Heartmate II LVAD implant while 27% received Heartware HVAD. Eighty-one percent were implanted as bridge to heart transplantation, 19% as destination therapy. Forty-five episodes of LVADIs occurred in 25 patients. Overall LVADI incidence was 47.5 cases per 100 patient-years. Driveline infections (58%) were the commonest type of LVADI. The commonest causative organisms were coagulase-negative staphylococci (33%), Staphylococcus aureus (31%) and Corynebacterium species (19%). Twelve percent of patients with LVADI required surgical debridement and one patient required pump exchange due to pump pocket infection. All-cause mortality was 13%. CONCLUSIONS: The findings of our study add to the understanding and epidemiology of LVADIs, particularly in the Asian setting. This can contribute to the development of evidence based strategies to prevent and manage LVADIs.

Percutaneous Decommissioning of Left Ventricular Assist Device.

BACKGROUND: The left ventricular assist device (LVAD) has revolutionised our treatment of advanced stage heart failure, giving debilitated patients a new lease on life. A small proportion of these LVAD patients can be bridged-to-recovery. The identification of these patients and decision to wean, however, can be challenging. METHODS: The need to fully explant the device upon recovery has evolved to a minimalist approach aiming to avoid injury to the 'recovered' heart. A review of the evolution of explant strategies was performed to guide our decision to wean the LVAD in our early experience. RESULTS: Between 2009 and 2014, two patients in our series of 69 LVAD implants (2.9%) were successfully weaned off their LVADs. The second patient had a minimal access implantation of his HeartWare Ventricular Assist Device (HVAD, Medtronic Inc, Framingham, MA, USA). His clinical variables and minimalist weaning strategy are described. CONCLUSIONS: A case of LVAD decommissioning by thrombosis of the outflow graft, using percutaneous Amplatzer Vascular Plug II (St. Jude Medical, St. Paul, MN, USA) without surgery is reported.

Therapeutic Hypothermia May Improve Neurological Outcomes in Extracorporeal Life Support for Adult Cardiac Arrest.

BACKGROUND: Limited data exists on patients receiving therapeutic hypothermia during extracorporeal life support (ECLS). We investigated outcomes and prognostic factors in these patients. METHODS: A retrospective review was conducted for 225 consecutive adult patients treated with ECLS between July 2003 and January 2016. Extracorporeal life support was initiated for refractory cardiac arrest (>10 mins) in 79 patients (35.1%). Patient demographics, ECLS-related complications, in-hospital mortality and neurological outcomes were analysed. RESULTS: The mean age was 49.9±12.4 years. Sixty-two patients (78.5%) were male. The mean duration of CPR and ECLS were respectively, 32.0±23.3 mins and 5.4±4.0 days. Therapeutic hypothermia (34oC) was maintained for 24hours in 14 patients (17.7%). Thirty-five patients (44.3%) were weaned off ECLS. Twenty-one patients (26.6%) survived to hospital discharge with 16 (20.3%) recovering good neurological function. Compared to ECLS at normothermia, neurologically favourable survival was higher in the hypothermia group (42.9% vs 15.4%, p=0.020). Multivariable analysis identified a non-shockable rhythm [odds ratio (OR) 5.1, confidence interval (CI) 1.5-16.8], ischaemic hepatitis (OR 6.2, CI 1.1-33.6) and hypoxic ischaemic encephalopathy (OR 5.1, CI 1.5-17.1) as predictors of in-hospital mortality. Therapeutic hypothermia (OR 4.9, CI 1.2-20.4) and acute renal failure (OR 0.19, CI 0.05-0.70) were predictors of neurologically favourable survival. CONCLUSIONS: In this report of patients treated with ECLS, in-hospital survival and survival with good neurological performance were 26.6% and 20.3% respectively. A non-shockable rhythm, ischaemic hepatitis and hypoxic ischaemic encephalopathy were predictors of in-hospital mortality. Therapeutic hypothermia during ECLS was associated with improved neurological outcomes.

Mechanical circulatory support and heart transplantation in the Asia Pacific region.

Globalization has resulted in epidemiologic transition in developing countries from infectious disease and nutritional deficiencies to non-communicable diseases. Epidemiologic data on heart failure (HF), particularly advanced HF therapy, in Asia are increasingly becoming available, although they remain sparse. Heart transplantation for advanced stage HF remains very low in Asia-approximately 0.075 heart transplants per 1 million population. North America, which comprises 7.5% of the world population, accounted for 55.8% of transplants recorded in the 2012 International Society for Heart and Lung Transplantation (ISHLT) Registry, whereas Asia, with 62.5% of the world population, accounted for 5.7% of transplants. There is also lack of reporting from heart transplant centers in Asia to the ISHLT Registry. Most transplant programs in Asia are in economically stable South East Asian countries, whereas in other parts of developing countries, the cost and health care infrastructures remain prohibitive for the development of these programs. Multi-cultural and racial factors, religious beliefs, and diverse traditions of many centuries have resulted in reluctance to organ donation. Mechanical circulatory support (MCS) is emerging as a viable alternative to transplantation, but despite technical capabilities, limitations in embracing MCS in Asia exist. Discrepant practices in the reimbursement of costly MCS therapy have led to differences in the availability of these devices to patients in the region. The HeartMate II (St. Jude Medical, Inc, St. Paul, MN) left ventricular assist device is currently the most widely used durable device in Asia, whereas the HeartWare HVAD (HeartWare, Inc, Framingham, MA) is used most often in Australia. By September 9, 2015, 341 HeartMate implants (293 as bridge to transplant and 48 as destination therapy) had been performed, of which 180 implants were in Japan. The overall 4-year survival is 88%. The longest duration of support is 6.5 years. By the end of 2015, 243 HeartWare HVADs had been implanted in Asia Pacific. There is a need for focused efforts at improving the reporting of data and intensifying health policy within the region to advocate organ transplantation. Individual governments need to take national responsibility to fulfill organ donation and transplantation needs of their populations. International collaboratives, coordinated by societies such as the ISHLT, will be essential in moving this field forward in Asia Pacific.

Therapeutic hypothermia in adult patients receiving extracorporeal life support: early results of a randomized controlled study.

Cardiac arrest with cerebral ischaemia frequently leads to severe neurological impairment. Extracorporeal life support (ECLS) has emerged as a valuable adjunct in resuscitation of cardiac arrest. Despite ECLS, the incidence of permanent neurological injury remains high. We hypothesize that patients receiving ECLS for cardiac arrest treated with therapeutic hypothermia at 34 °C have lower neurological complication rates compared to standard ECLS therapy at normothermia. Early results of this randomized study suggest that therapeutic hypothermia is safe in adult patients receiving ECLS, with similar complication rates as ECLS without hypothermia. Further studies are warranted to measure the efficacy of this therapy.

Contained Rupture in HeartMate II Outflow Graft Bend Relief Disconnection.

Thoratec recalled their HeartMate II ventricular assist device in March 2012 after some problems related to disconnection of the bend relief. Abrasion on the pump outflow graft caused by a disconnected bend relief is rare. We report the case of a 49-year-old man in whom a disconnected bend relief caused a puncture in the outflow graft, resulting in a contained hematoma, requiring outflow graft replacement.

"Burnt out" dilated hypertrophic cardiomyopathy causing acute LVAD thrombosis.

Case report illustrates obstruction encountered in a patient with end-stage dilated hypertrophic cardiomyopathy (HCM) who underwent LVAD implantation. The morphology reversed in early postoperative period to HCM. Pump replacement required coring of the ventricular muscle. Dilated end-stage hypertrophic cardiomyopathy can revert back to the original morphology on decompression.

Use of left ventricular assist device (HeartMate II): a Singapore experience.

Recent advances in medical and device therapies in heart failure have improved the survival of patients with heart failure. However, due to the limited availability of suitable heart donors, left ventricular assist devices (LVADs) have become an important tool as a bridge-to-heart transplantation for patients with refractory heart failure in Singapore. We report our experience with the HeartMate II (HMII) LVAD (Thoratec Corporation, Pleasanton, CA, USA) as a bridge-to-heart transplant in our center from 2009 to 2012. This was a retrospective review of 23 consecutive patients who underwent HMII LVAD implantation in our center between May 2009 and December 2012. All patients were classified as Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels 1 to 3 and underwent LVAD implantation as a bridge-to-heart transplant. There were 17 male and 6 female patients. The mean age was 43.6 years old (range 14 to 64). The etiologies of heart failure included ischemic heart disease [8], idiopathic dilated cardiomyopathy [11], viral myocarditis [2], and chemotherapy-induced cardiomyopathy [2]. Nine patients were INTERMACS level 1, 12 patients level 2, and two patients level 3. All patients successfully underwent HMII LVAD implantation. There was no mortality within the first 30 postoperative days. Postoperative complications included stroke with full neurological recovery (21.7%), mediastinal infection (21.7%), cardiac tamponade or mediastinal collection requiring reopening of the chest (39.1%), cardiac arrhythmia (13.0%), and pump thrombosis with pump replacement (4.3%). All patients were discharged from hospital after LVAD implantation. Three patients experienced driveline infections during outpatient follow-up. There were 19 readmissions due to the following conditions: sub-therapeutic anticoagulation (13.0%), gastrointestinal bleeding (13.0%), suspected pump thrombosis (13.0%), transient ischemic attack (8.7%), arrhythmia (8.7%), congestive cardiac failure due to severe aortic regurgitation (8.7%), right ventricular failure (4.3%), rhabdomyolysis (4.3%), and hematuria (4.3%). Post-LVAD implantation, 20 patients were functionally New York Heart Association (NYHA) class I, while 3 reported NYHA III symptoms. Three patients were successfully bridged to heart transplantation. One patient was successfully explanted 11 months after LVAD implantation. There were two mortalities during the follow-up period. The average duration of LVAD support was 522 days (range 47 to 1316 days). The HeartMate II LVAD has proven to be effective in our Asian population. Driveline infection rate remains low even in the tropical hot, humid climate in Singapore. With more patients ending up on extended periods of LVAD support, increased emphasis in the detection and management of long-term complications of ventricular assist devices will be needed.