Contemporary Trends of Clinical Outcomes in Primary Left Ventricular Assist Device Implantation and Postprocedure High-Risk Categories

ObjectiveWe aimed to analyze trends of 30-day readmission and find high-risk patients associated with increased risk of mortality, resource use, and readmission after primary left ventricular assist device (LVAD) implantation. Limited data exist on the contemporary trends of readmission rates and patients at a higher risk of worse outcomes after LVAD implantation.Methods and ResultsThis is a retrospective study of adults from the Nationwide Readmission Database who underwent primary durable LVAD implantation from 2010 to 2018. The main outcomes were 30-day readmission rates and their trends in patients with primary durable LVAD implantation from 2010 to 2018. This study also sought to identify patients at the highest risk for readmission, in-hospital mortality, and resource use. A total of 31,002 adults with primary durable LVAD implantation were included in the present analysis. Overall, 3808 patients (12.3%) died and 27,168 (87.6%) were discharged alive. Of those discharged alive, 8303 patients (30.6%) were readmitted within 30 days. The trend of 30-day all-cause readmission among LVAD implantation patients remained similar from 2010 to 2018 (P = .809). The in-hospital mortality rate during the index hospitalization decreased significantly (P = .014), and the mean cost of an index hospitalization increased (P = .031) during the study period. The patients with post-LVAD in-hospital cardiac, vascular, and thromboembolic complications (ie, high-risk patients) had the highest mortality, resource use, and readmission rates compared with patients without major complications.ConclusionsThis study found that the readmission rates associated with LVAD implantation did not change from 2010 to 2018 and identified high-risk patients who may benefit from closer monitoring after primary LVAD implantation.     

Timing and Trends of Right Atrial Pressure and Risk of Right Heart Failure After Left Ventricular Assist Device Implantation

BackgroundElevated right atrial pressure (RAP) is associated with poor outcomes after left ventricular assist device (LVAD) implantation. However, the optimal time for RAP measurement and the importance of resolution of right heart congestion prior to LVAD implantation remain unclear.Methods and ResultsWe performed a retrospective cohort study of 134 consecutive LVAD recipients from our institution. Congestion was defined as RAP ≥ 14 mmHg and was assessed at hospital admission and implant. The primary outcome was death or right ventricular assist device (RVAD) implantation. When stratified by congestion status at admission, congested and non-congested patients had similar event-free survival rates (hazard ratio [HR]: 1.2, 95% confidence interval [CI]: 0.6–2.6). However, when stratified at implant, congested patients had a higher rate death or RVAD implantation (HR: 2.5, 95% CI: 1.1–5.6). Patients were then divided into 4 groups based on their trajectory of congestion status: no congestion, resolved congestion, new congestion, or persistent congestion. Patients with no congestion and resolved congestion had similar outcomes, whereas patients with persistent congestion had a markedly increased rate of death or RVAD implantation (HR: 3.1, 95% CI: 1.3–7.6).ConclusionRAP at LVAD implantation is more strongly associated with postoperative outcomes than admission RAP. Patients not responsive to decongestive therapies, with persistently elevated RAP, represent a high-risk cohort for adverse outcomes following LVAD implantation.     

Left Ventricular Assist Device Caregiver Experiences and Health Outcomes: A Systematic Review of Qualitative and Quantitative Studies

BackgroundKnowledge synthesis is lacking regarding outcomes and experiences of caregivers of adult patients living with continuous flow left ventricular assist devices (CF-LVAD). The purpose of this systematic review was to summarize qualitative data related to the experience of caregivers of adult patients living with CF-LVAD as well as quantitative data related to health outcomes of caregivers.Methods and ResultsMultiple databases were systematically queried for studies of qualitative experiences and quantitative health outcomes for caregivers of adult CF-LVAD recipients. Search dates were constrained to articles published between 2004 and August of 2018 because CF-LVADs were not routinely implanted before 2004. Two authors independently screened 683 articles; 15 met predetermined inclusion criteria. Eligible articles reported results from 13 studies. Of those, 8 used either qualitative or mixed methods and 5 used quantitative methods. Caregivers were primarily female (81%) and their mean age was 59 years. Qualitative studies revealed 3 overarching themes related to the caregiver role, coping strategies, and LVAD decisions. Quantitative studies revealed caregiver strain peaked between 1 and 3 months after implantation, anxiety and depression were relatively stable, mental health status improved, and physical health status was stable from before to after implantation.ConclusionsCF-LVAD caregivers experience significant, sustained emotional strain for 3 months after implantation, reporting considerable stress in meeting their personal needs and those of their loved one.     

Right Ventricular Systolic and Diastolic Function as Assessed by Speckle-Tracking Echocardiography Improve With Prolonged Isolated Left Ventricular Assist Device Support

BackgroundRight ventricular (RV) failure is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Whether RV function deteriorates with prolonged LVAD support is unknown. Speckle-tracking echocardiography provides a sensitive, noninvasive, reproducible, and quantitative assessment of RV systolic and diastolic function.MethodsEchocardiograms were retrospectively reviewed from before and after implantation of a Heartmate II LVAD. Speckle-tracking analysis was performed to measure RV longitudinal systolic strain, strain rate, and diastolic strain rate for each patient at baseline and over discrete time periods after LVAD implantation.ResultsSeventeen patients were included in the analysis, with an average follow-up after LVAD implantation of 234 ± 125 days. RV systolic strain improved in 15 patients, decreasing from −7.4 ± 2.3% to −9.7 ± 3.3% after LVAD (P = .026). Systolic strain rate improved in 11 patients, decreasing from −0.67 ± 0.25%/s to −0.96 ± 0.36%/s (P = .011). RV diastolic strain rate improved in 12 patients, increasing from 0.70 ± 0.33%/s to 1.02 ± 0.40%/s (P = .016).ConclusionsChronic LVAD support improves RV systolic and diastolic function in LVAD patients who did not require an RV assist device. Speckle-tracking echocardiography may offer a noninvasive technique for identifying and monitoring improvements in RV function in LVAD patients.     

Outcomes in Patients With Chronic Kidney Disease and End-stage Renal Disease and Durable Left Ventricular Assist Device: Insights From the United States Renal Data System Database

BackgroundThere is paucity of data regarding durable left ventricular assist device (LVAD) outcomes in patients with chronic kidney disease (CKD) stages 3–5 and CKD stage 5 on dialysis (end-stage renal disease [ESRD]).Methods and ResultsWe conducted a retrospective study of Medicare beneficiaries with ESRD and a 5% sample of patients with CKD with an LVAD (2006–2018) to determine 1-year outcomes using the United States Renal Data System database. The LVAD implantation, comorbidities, and outcomes were identified using appropriate International Classification of Diseases, 9th and 10th edition codes. We identified 496 patients with CKD and 95 patients with ESRD who underwent LVAD implantation. The patients with ESRD were younger (59 years vs 66 years; P < .001), had more Blacks (40% vs 24.6%, P = .009), compared with the CKD group. The 1-year mortality (49.5% vs 30.9%, P < .001) and index mortality (27.4% vs 16.7%, P = .014) rates were higher for patients with ESRD. A subgroup analysis showed significantly higher mortality in ESRD vs CKD 3 (49.5% vs 30.2%, adjusted P = .009), but no significant difference in mortality between stage 3 vs 4/5 (30.2% vs 30.8%, adjusted P = .941). There was no significant difference in secondary outcomes (bleeding, stroke, and sepsis/infection) during follow-up between the 2 groups.ConclusionsPatients with ESRD undergoing LVAD implantation had significantly higher index and 1-year mortality rates compared with patients with CKD.     

A bridge to transplantation: The life experiences of patients with a left ventricular assist device

BackgroundThe Left Ventricular Assist Device (LVAD) is a rapidly spreading treatment given to patients with advanced heart failure due to organ donor shortage. Thus, there is a need to study the life experience of patients who underwent LVAD implantation as a bridge to transplantation.ObjectiveTo examine the life experiences of patients who underwent LVAD implantation as a bridge to transplantation.MethodsThis qualitative, phenomenological research was carried out with 13 patients who underwent LVAD implantation as a bridge to transplantation. Data were collected through semi-structured in-depth interviews. Interviews were recorded through an audio recorder, transcribed verbatim, and evaluated using the inductive content analysis method.ResultsTwo main themes (fear and coping), each with four sub-themes, were obtained after data were analyzed. Participants’ fears and coping strategies for these were identified.ConclusionIn this study, fears and coping strategies came to the forefront in the life experiences of patients who underwent LVAD implantation as a bridge to transplantation.     

Dynamic Assessment of Pulmonary Artery Pulsatility Index Provides Incremental Risk Assessment for Early Right Ventricular Failure After Left Ventricular Assist Device

BackgroundThe pulmonary artery pulsatility index (PAPi) has been studied to predict right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation, but only as a single time point before LVAD implantation. Multiple clinical factors and therapies impact RV function in pre-LVAD patients. Thus, we hypothesized that serial PAPi measurements during cardiac intensive care unit (CICU) optimization before LVAD implantation would provide incremental risk stratification for early RVF after LVAD implantation.Methods and ResultsConsecutive patients who underwent sequential pulmonary artery catherization with cardiac intensive care optimization before durable LVAD implantation were included. Serial hemodynamics were reviewed retrospectively across the optimization period. The optimal PAPi was defined by the initial PAPi + the PAPi at optimized hemodynamics. RVF was defined as need for a right ventricular assist device or prolonged inotrope use (>14 days postoperatively). Patients with early RVF had significantly lower mean optimal PAPi (3.5 vs 7.5, P < .001) compared with those who did not develop RVF. After adjusting for established risk factors of early RVF after LVAD implantation, the optimal PAPi was independently and incrementally associated with early RVF after LVAD implantation (odds ratio 0.64, 95% confidence interval 0.532–0.765, P < .0001).ConclusionsOptimal PAPi achieved during medical optimization before LVAD implantation provides independent and incremental risk stratification for early RVF, likely identifying dynamic RV reserve.     

Trends and outcomes of device-related 30-day readmissions after left ventricular assist device implantation

BackgroundLeft ventricular assist devices (LVAD) improve morbidity and mortality in end-stage heart failure patients, but high rates of readmissions remain a problem after implantation. We aimed to assess the incidence, trends, outcomes, and predictors of device-related 30-day readmissions after LVAD implantation.MethodsThe National Readmission Database was used to identify patients who underwent LVAD implantation between 2012 and 2017 and those with 30-day readmissions.ResultsThe analysis included a total of 16499 adults who survived the index hospitalization for LVAD implantation. Among those, 28.1% were readmitted at 30 days, and the readmission rate has been grossly stable during the study period. Most of the readmissions occurred in the first 15 days after discharge from the index admission. The most frequent cause of readmissions was gastrointestinal bleeding (14.9% of readmissions), followed by heart failure, arrhythmias, device infection, and device thrombosis. Among reasons for readmission, intracranial bleeding was associated with highest mortality (37.6%), followed by device thrombosis (13.1%), and ischemic stroke (7.6%). Intracranial bleeding and device thrombosis were associated with lengthier stay (20.4 and 15.5 days, respectively). Readmission rates for gastrointestinal bleeding decreased, whereas device infection increased. Multivariate logistic regression model revealed the length of stay, oxygen dependence, gastrointestinal bleeding at index admission, depression and ECMO, private insurance as independent predictors of 30-day readmission.ConclusionOver one-fourth of LVAD recipients have 30-day readmissions, with most of them occurring within 15 days. Most frequent cause of readmission was gastrointestinal bleeding, which was associated with the lowest in-hospital mortality among other complications.     

Health Literacy in Patients Considering a Left Ventricular Assist Device: Findings From the DECIDE-LVAD Trial

ObjectiveTo assess the interaction of health literacy and a shared intervention concerning decision quality in patients considering the destination therapy of left ventricular assist device (DT LVAD) implantation.BackgroundEvidence is limited for the use of decision aids by patients with low health literacy and with life-threatening illnesses.MethodsWe performed a secondary analysis of the DECIDE-LVAD Trial, a randomized, stepped-wedge trial conducted from 2015–2017 in the United States. The intervention was the integration of a formal shared decision-making intervention. The main outcome was decision quality as measured by LVAD knowledge and values-treatment concordance. Two components of health literacy were measured by the Rapid Estimate of Adult Literacy in Medicine and Subjective Numeracy Scale instruments.ResultsOf the 228 patients studied, 44% (n = 101) received the formal shared decision-making intervention, and half had low health literacy. Knowledge of LVAD improved for patients with low literacy in the intervention group compared to the control group: the difference in increased knowledge score was 10.6%; P = 0.04. Values-treatment concordance improved significantly for patients with low literacy in the intervention group compared to the control group: the median improvement in values-treatment correlation coefficient was 0.43; P = 0.03. These benefits were not significant in those with adequate literacy (n = 171). Patients with low numeracy (n = 94) did not show significant improvements in either measure of decision quality, and patients with adequate numeracy (n = 134) showed improvement in LVAD knowledge but not in values-treatment concordance.ConclusionsPatients considering DT LVAD implantation with low literacy showed improvement in decision quality after the integration of a shared decision-making intervention.     

Impact of chronic kidney disease on in-hospital outcomes following left ventricular assist device placement: A national perspective

BackgroundLeft ventricular assist devices (LVADs) are being increasingly utilized for the treatment of stage-D heart failure. A LVAD is a battery-operated, mechanical pump that assists in pumping blood out of the left ventricle (LV) into the aorta, thereby lowering left ventricular burden. Prevalence of chronic kidney disease (CKD) is increasing in patients receiving LVAD.ObjectivesThe purpose of this study was to compare in-hospital mortality and hospitalization expenditure associated with CKD in patients receiving LVAD implantation.MethodsUsing the National Inpatient Sample from January 2012 through September 2015, index hospitalizations for LVAD were identified. Based on kidney function, LVAD recipients were divided into three groups: Group 1 included patients with normal renal function or CKD stages I–III. Groups 2 and 3 comprised of patients with CKD stage IV/V, and end-stage renal disease on dialysis respectively.ResultsA total of 20,656 patients received LVAD during the study period. Mean age was 56.1 years; 76.8% were men. In a fully adjusted model, in-hospital mortality was higher in group 2 (OR: 1.33, CI: 1.16–1.50) and highest in group 3 (OR: 8.95, CI: 6.90–11.61). Similarly, the length of hospitalization, and hospitalization cost were higher in group 2 and highest in group 3.ConclusionDespite improving outcomes in patients receiving LVAD, CKD remained a significant health problem. Worsening in-hospital outcomes paralleling the degree of kidney dysfunction were observed in patients receiving LVADs in this study.     

Assessment of pre-operative psychosocial function among people receiving left ventricular assist devices: A national survey of US LVAD programs

BackgroundThe International Society for Heart & Lung Transplantation (ISHLT) guidelines for Mechanical Circulatory Support (MCS) includes assessment of four elements of psychosocial functioning prior to Left Ventricular Assist Device (LVAD) implantation. Information about the practices and impact of assessments of psychosocial functioning are limited.ObjectiveTo describe the psychosocial function assessment practices used within US LVAD programs and the influence of psychosocial assessment results on clinical decisions for LVAD patient selection.MethodsIn 2017, a cross-sectional survey of LVAD programs listed in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) (N = 164) was conducted to understand practices used for and the influence of psychosocial assessments for post-operative care planning decisions.ResultsRespondents included representatives of 69 LVAD programs from throughout the U.S. that implanted 64.8% of all U.S LVADs in 2016. More than 39 psychosocial screening instruments were used. Assessment of family, social and emotional support occurred most frequently (84.1% (n = 58) of programs assessed 100% of patients), but assessment was least likely to be conducted with standardized instruments (36.2%). Cognitive dysfunction was the least likely characteristic to be assessed (26.1% (n = 18) of programs assessed 100% of patients), but was most often conducted with standardized instruments (53.8% of programs). Twenty seven percent of programs used non-standardized instruments or patient observation. The influence of assessments on clinical decisions to implant an LVAD was most influential in the bridge to transplant pathway with 60% (n = 39) of respondents rating it very influential and least influential for patients in the destination therapy pathway with 39.4% (n = 26) of respondents.ConclusionsCurrent psychosocial assessment practices in LVAD programs vary widely and often yield non-standardized, non-comparable data that may lead to variations in care and limit generation of an evidence base for decision making regarding psychosocial eligibility for LVAD implantation.     

Complications of LVAD utilization in older adults

BackgroundYearly rate and mean patient age of left ventricular assist device (LVAD) implantation increased from 2009 to 2014. Data are lacking regarding trends of LVAD implantation in older adults.ObjectivesTo describe the trends of LVAD implantation in older adults and the clinical impact of associated procedural complications.MethodsWe retrospectively analyzed the National Inpatient Sample from 2005 to 2014, calculated the percentage of older adults (>65 years of age) among those who underwent LVAD implantation, and compared their clinical characteristics. Primary outcomes were in-hospital mortality and discharge home.ResultsIn total, 4491 patients were included. The percentage of older adults among those receiving LVAD increased from 12.53% to 31.65% (p<0.01). Older adults were more likely to develop postoperative delirium (17.90% vs. 11.92% in younger patients; p<0.01), which portended lesser odds of discharge home.ConclusionsDelirium develops with greater incidence in older adults undergoing LVAD implantation, which decreases odds of favorable discharge disposition.     

Standardized Use of the Stanford Integrated Psychosocial Assessment for Transplantation in LVAD Patients

BackgroundIncreased psychosocial risk portends poor outcomes following heart transplantation. The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a validated, psychosocial risk assessment tool that helps stratify candidates for transplantation. We assessed the impact of psychosocial factors as measured by the SIPAT on clinical outcomes following left ventricular assist device (LVAD) implantation at our institution.Methods and ResultsA total of 115 individuals (mean age: 57 years, 75.6% men) who underwent LVAD implantation, for either bridge-to-transplant (63%) or destination therapy, from 2014 to 2016 were included for analysis. Correlations between SIPAT scores, baseline characteristics, and post-LVAD outcomes were assessed through a retrospective correlational design. At 1 year post-LVAD, the higher risk SIPAT group had more emergency department visits, urgent clinic visits, and readmissions in univariate analysis (rate ratio 1.7 [95% confidence interval (CI) 1.0–2.7, P = .035]). After multivariate analysis, this association retained near-statistical significance (rate ratio 1.6 [95% CI 1.0–2.8, P = .051]). There was also a trend toward more device-associated infections (rate ratio 2.1 [95% CI 0.96–4.4, P = .064]). There was no difference in incidence of other adverse events or 1-year mortality between the 2 groups.ConclusionsHigher psychosocial risk per SIPAT in patients undergoing LVAD implantation is associated with more emergency room visits, urgent visits and readmissions over 1 year, but not LVAD-related complications or mortality. Use of the SIPAT tool may help identify patients at higher risk for hospitalization and/or urgent care beyond traditional factors, but should not preclude LVAD implantation.     

Pulmonary artery pulsatility index predicts prolonged inotrope/pulmonary vasodilator use after implantation of continuous flow left ventricular assist device

Objective: Predictors of right ventricle (RV) dysfunction after continuous‐flow left ventricular assist device (CF‐LVAD) implantation in children are not well described. We explored the association of preimplantation Pulmonary Artery Pulsatility index (PAPi) and other hemodynamic parameters as predictors of prolonged postoperative inotropes/pulmonary vasodilator use after CF‐LVAD implantation.
Design: Retrospective chart review.
Setting: Single tertiary care pediatric referral center.
Patients: Patients who underwent CF‐LVAD implantation from January 2012 to October 2017.
Interventions: Preimplantation invasive hemodynamic parameters were analyzed to evaluate the association with post‐CF‐LVAD need for prolonged (>72 hours) use of inotropes/pulmonary vasodilators.
Measurements and main results: Preimplantation cardiac catheterization data was available for 12 of 44 patients who underwent CF‐LVAD implant during the study period. Median (IQR) age and BSA of the cohort were 15.3 years (10.2, 18) and 1.74 m2 (0.98, 2.03). Group 1 (n = 6) included patients with need for prolonged inotropes/pulmonary vasodilator use after CF‐LVAD implantation and Group 2 (n = 6) included those without. Baseline demographic parameters, cardiopulmonary bypass time, and markers of RV afterload (pulmonary vascular resistance, PA compliance and elastance) were similar among the two groups. PAPi was significantly lower in group 1 compared to group 2 (0.96 vs 3.6, respectively; P = .004). Post‐LVAD stay in the intensive care unit was longer for patients in group 1 (46 vs 23 days, P = .52). Brain natriuretic peptide was significantly higher at 3 months after implantation in group 1; P = .01.
Conclusions: The need for inotropes/pulmonary vasodilators in the postoperative period can be predicted by the preimplantation intrinsic RV contractile reserve as assessed by PAPi rather than the markers of RV afterload. Further investigation and correlation with clinical outcomes is needed.     

Impact of Socioeconomic Factors on Patient Desire for Early LVAD Therapy Prior to Inotrope Dependence

BackgroundWorsening heart failure (HF) and health-related quality of life (HRQOL) have been shown to impact the decision to proceed with left ventricular assist device (LVAD) implantation, but little is known about how socioeconomic factors influence expressed patient preference for LVAD.Methods and ResultsAmbulatory patients with advanced systolic HF (n=353) reviewed written information about LVAD therapy and completed a brief survey to indicate whether they would want an LVAD to treat their current level of HF. Ordinal logistic regression analyses identified clinical and demographic predictors of LVAD preference. Higher New York Heart Association (NYHA) class, worse HRQOL measured by Kansas City Cardiomyopathy Questionnaire, lower education level, and lower income were significant univariable predictors of patients wanting an LVAD. In the multivariable model, higher NYHA class (OR [odds ratio]: 1.43, CI [confidence interval]: 1.08–1.90, P = .013) and lower income level (OR: 2.10, CI: 1.18 – 3.76, P = .012 for <$40,000 vs >$80,000) remained significantly associated with wanting an LVAD.ConclusionAmong ambulatory patients with advanced systolic HF, treatment preference for LVAD was influenced by level of income independent of HF severity. Understanding the impact of socioeconomic factors on willingness to consider LVAD therapy may help tailor counseling towards individual needs.     

Pre-implant left ventricular dimension is not associated with worse outcomes after left ventricular assist device implantation

BackgroundLeft ventricular dimension has the potential to impact clinical outcomes following implantation of left ventricular assist devices (LVAD). We investigated the effect of pre-implant left ventricular end-diastolic diameter (LVEDD) on outcomes following LVAD implantation.MethodsPatients implanted with a continuous-flow LVAD between 2004 and 2018 at a single institution were included. The primary outcome was death while on LVAD support. Secondary outcomes included adverse event rates such as renal failure requiring dialysis, device thrombosis, and right ventricular failure. The LVEDD measurements were dichotomized using restricted cubic splines and threshold regression. Survival was determined using Kaplan-Meier estimates. Multivariable logistic regression was used to determine risk-adjusted mortality based on LVEDD.ResultsA total of 344 patients underwent implantation of a continuous flow LVAD during the study period. The optimal cut point for LVEDD was 65 mm, with 126 (36.6%) subjects in the <65 mm group and 165 (48.0%) in the >65 mm group. The LVEDD <65 mm group was older, had more females, higher incidence of diabetes, more pre-implant mechanical ventilation, and more admissions for acute myocardial infarctions (all, P<0.05). Importantly, post-implant adverse events were similar between the groups (all, P>0.05). Risk-adjusted survival at 1-year (OR 1.3, 95% CI: 0.6–2.5, P=0.53) was also comparable between the groups. Furthermore, incremental increases in LVEDD when modeled as a continuous variable did not impact overall mortality (OR 0.98, 95% CI: 0.9–1.0, P=0.09).ConclusionsPreoperative LVEDD was not associated with rates of major morbidities or mortality following LVAD implantation.     

Incidence and impact of ischemic and hemorrhagic stroke after left ventricular assist device implantation: A nationwide study

BackgroundDespite noteworthy advancements in the design of the left ventricular assist device (LVAD), stroke remains one of the most significant adverse events. This study aims to analyze the incidence and short-term outcomes associated with stroke (ischemic and hemorrhagic) after implantation of LVAD.MethodsStudy cohorts were identified from the National Inpatient Sample database from January 2009 to September 2015 using the International Classification of Diseases, Ninth Revision codes. The primary outcome was an incidence of stroke, and secondary outcomes were the associated mortality, length of stay, and cost of hospitalization. A multivariate logistic regression analysis was performed to analyze adjusted in-hospital mortality.ResultsUse of LVADs increased significantly from 2009 to 2014 (2278 in 2009 to 3730 in 2014 [P_trend <0.001]). From a total of 20,656 admissions who underwent LVAD implantation, 1518 (7.4%) developed stroke, among whom 1177 (5.7%) had an ischemic stroke and 426 (2.1%) had a hemorrhagic stroke. Adjusted in-hospital mortality was highest with hemorrhagic stroke. Incidence of stroke was associated with significantly longer length of stay and cost of hospitalization.ConclusionThe incidence of stroke was ~7% after LVAD placement, and it was associated with significantly higher in-hospital mortality and resource utilization.     

Decisional regret in left ventricular assist device patient-caregiver dyads

BackgroundThe objective of this study was to investigate decisional regret among left ventricular assist device (LVAD) patients and their caregivers.MethodsThis study was a single center, cross-sectional survey of patients after LVAD implantation and their caregivers. Subjects were recruited at their outpatient heart failure appointments. Patients and caregivers at least three months from LVAD implantation completed a 5-item, validated decisional regret scale. Summative scores on a 0–100 point scale were determined for patient and caregivers (0 = no regret). Subgroup analysis included gender, LVAD indication (bridge to transplant (BTT) or destination therapy (DT)), time from LVAD implantation, and caregiver relationship. Dyad discordance was defined as a patient-caregiver difference of ≥2 points on any regret scale question.ResultsFifty patients were approached for participation. Thirty-three LVAD patient-caregiver dyads were enrolled in the study (19 male, 14 female patients; 8 male, 25 female caregivers). Patients had a mean age of approximately 50 years. Caregivers had a mean age of approximately 54 years. Patients had a median regret score of 10 (Interquartile range (IQR): 0–30), while caregivers had a median regret score of 20 (IQR: 0–25). Median regret scores of female patients were significantly higher than that of male patients (27.5 vs 0, p = 0.0038). BTT patients had numerically lower regret than DT patients, but this was not statistically significant. Patients who had been implanted for greater than three years had the highest regret scores. Discordance in at least one domain of the regret scale was present in 19 out of 33 (57.6%) dyads.ConclusionsWhile decisional regret was reasonably low in this population, comparatively, there was significantly increased decisional regret among female patients and patients further from LVAD implantation. Differences between patients and caregivers were also observed. These findings highlight the need for robust support and continual attention to expectations before and after LVAD implantation.     

Effects of left ventricular assist device on pulmonary functions and pulmonary hemodynamics: A meta-analysis

BACKGROUNDGiven current evidence, the effect of left ventricular assist device (LVAD) implantation on pulmonary function tests remains controversial.AIMTo better understand the factors contributing to the changes seen on pulmonary function testing and the correlation with pulmonary hemodynamics after LVAD implantation.METHODSElectronic databases were queried to identify relevant articles. The summary effect size was estimated as a difference of overall means and standard deviation on a random-effects model.RESULTSA total of four studies comprising 219 patients were included. The overall mean forced expiratory volume in one second (FEV1), forced vital capacity (FVC) and diffusion lung capacity of carbon monoxide (DLCO) after LVAD implantation were significantly lower by 0.23 L (95%CI: 0.11-0.34, P = 00002), 0.18 L (95%CI: 0.03-0.34, P = 0.02), and 3.16 mmol/min (95%CI: 2.17-4.14, P < 0.00001), respectively. The net post-LVAD mean value of the cardiac index was significantly higher by 0.49 L/min/m² (95%CI: 0.31-0.66, P < 0.00001) compared to pre-LVAD value. The pulmonary capillary wedge pressure and pulmonary vascular resistance were significantly reduced after LVAD implantation by 8.56 mmHg (95%CI: 3.78-13.35, P = 0.0004), and 0.83 Woods U (95%CI: 0.11-1.55, P = 0.02), respectively. There was no significant difference observed in the right atrial pressure after LVAD implantation (0.61 mmHg, 95%CI: -2.00 to 3.32, P = 0.65). Overall findings appear to be driven by studies using HeartMateII devices.CONCLUSIONLVAD implantation might be associated with a significant reduction of the spirometric measures, including FEV1, FVC, and DLCO, and an overall improvement of pulmonary hemodynamics.