Reasons for, and outcomes of patients who were referred for a ventricular assist device but were declined: the recent era forgotten ones.

BACKGROUND: 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. METHODS: For this study, the Artificial Heart Program's database at Intermountain Medical Center was queried from 2006 to 2012 for patients referred for a VAD. Kaplan-Meier survival analysis was performed with log-rank test determining significance. RESULTS: Of 232 patients included, 118 patients received a VAD and 114 patients did not. The prevailing reason for VAD decline in eligible and willing patients was due to pre-existing illness (39%). Mortality was higher in non-VAD vs. VAD patients (58.8% vs. 35.6%, p < 0.001) with a median time-to-death of 67 (IQR:12-314) and 301 (IQR:136-694) d, respectively (p = 0.007). CONCLUSIONS: In the current era of non-pulsatile VADs, mortality of patients who are considered but not implanted remains high. Additionally, mortality of these patients occurred much sooner. Educational efforts ensuring timely referral for VAD therapy are important to maximize the number of patients who may benefit.

Lactic acidosis after cardiac transplantation: foe or common innocent bystander?

BACKGROUND: Lactic acidosis (LA) frequently occurs after heart transplantation (HTx). It is hypothesized to be related to inotropic support or metabolic derangements from chronic heart failure. As such, restoring hemodynamic stability with mechanical circulatory support before HTx should mitigate this problem. Our aim was to evaluate the incidence and outcomes of LA after HTx. METHODS: We evaluated HTx recipients January 2000 to May 2011. Post-HTx outcomes included graft dysfunction, length of intensive care unit stay, length of hospital stay, inotropic support, and survival. RESULTS: Of 143 eligible patients, 98.6% had LA, 67% severe, after HTx. Data were analyzed based on the severity of LA. Time to peak lactate, intensive care unit stay, length of hospital stay, peak glucose, inotropic dose, graft dysfunction, and survival after HTx were similar between groups. Statistically significant differences included pretransplant support (25.6% mechanical circulatory support in nonsevere vs. 44.9% severe LA), hospitalization at the time of HTx (37.2% vs. 21.4%), glucose at the time of peak lactate (182.88 ± 69.80 vs. 221.31 ± 56.91), ischemic time (187.4 ± 63.1 vs. 215.5 ± 68.1), and duration of inotrope. CONCLUSION: Severe LA is common after HTx, though it appears to be transient and benign. Mechanical circulatory support after HTx does not prevent LA. High lactate levels are associated with longer ischemic times, longer duration of inotrope, and correspond with higher glucose levels. The underlying mechanism is yet to be satisfactorily elucidated.

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.

Obesity and left ventricular assist device driveline exit site infection.

Driveline exit site (DLES) infection is a persistent problem among the left ventricular assist device (LVAD) patients. This study investigated the relationship between obesity and DLES infection. Records of LVAD patients at two institutions from January 1999 to January 2009 were queried. Results were analyzed using t tests. Those with LVAD support > or =90 days were included. The body mass index (BMI) of each patient was measured at the time of implant and at the conclusion of LVAD support or currently, if the patient was ongoing. Other data included preimplant age, ejection fraction, blood urea nitrogen, creatinine, diabetes, New York Heart Association class, pulmonary capillary wedge pressure, VO2 max, and inotrope therapy. The 118 patients who qualified for the study were placed in an infection group (n = 36) or in the control group (n = 82). Both groups had similar preimplant characteristics. Variables with differences statistically significant between the groups included duration of LVAD support, indication for support, device type, and BMI. Patients who developed DLES infections had a significantly higher BMI and continued weight gain over the course of LVAD therapy compared with the control group. Although this association requires further study, implications for clinical practice may include the provision of nutrition and exercise counseling for patients undergoing LVAD therapy, especially if overweight. These results may warrant increased measures to prevent and treat infection in the preimplant and postimplant periods.

Outcome of noncardiac surgery in patients with ventricular assist devices.

An increasing number of patients are living with ventricular assist devices (VADs). Many of these patients will require noncardiac surgery for conditions not directly related to their VADs. The aim of this study was to assess the risks and outcomes of noncardiac surgery in these patients. Perioperative and follow-up data from patients with VADs who underwent noncardiac surgery from 1993 to 2006 were analyzed. In that period, 184 VADs were implanted in 155 patients. Thirty-seven patients (24%) subsequently underwent 59 noncardiac surgeries. The mean duration of VAD support before surgery was 229 days. Bleeding was the most common postsurgical complication (10%), necessitating reexploration in 20% of abdominal surgeries. Thirty-day mortality was 12%. No deaths were caused by direct complications of surgery. Successful transplantation occurred in 72% of bridge to transplantation patients who required noncardiac surgery, compared with 71% of these patients who did not require noncardiac surgery (relative risk 1.0, p = 0.9). The average duration of VAD support after noncardiac surgery for destination therapy patients was 324 days, most of which time was spent at home. In conclusion, outcomes after noncardiac surgery in patients with VADs are favorable, and most patients continue to benefit from the intended purpose of mechanical circulatory support after recovering from noncardiac surgery.