Advanced Heart Failure Clinic Research Articles

Mitochondrial function is abnormal in circulating blood monocytes of patients with chronic heart failure

Abstract Background Cardiac mitochondrial function is abnormal in heart failure (HF) and is likely to contribute to disease progression. We previously showed that in dogs with HF mitochondrial functional abnormalities exist in both failing cardiomyocytes and in circulating blood monocytes, and to similar extent. This finding suggested the possibility that mitochondrial function in circulating monocytes can serve as a surrogate for cardiac mitochondrial function. We also showed that mitochondrial abnormalities exist in cardiomyocytes of patients with chronic HF. Purpose In the present study we sought to test the difference between patients with advanced HF and age-matched controls in terms of circulating monocyte mitochondrial function. Methods We examined circulating blood monocytes from 10 patients evaluated in our advanced HF clinic and with left ventricular ejection fraction <35%. compared to 10 age-matched control persons without cardiac disease (CON). Peripheral blood samples (15 ml) were obtained from each participant and monocytes were isolated using standard Ficoll-Paque gradient centrifugation. Isolated monocytes were suspended in Agilent XF-DMEM base buffer for quantification of mitochondrial function with Seahorse XFe96 analyzer. The following key mitochondrial functional parameters were determined: basal respiration (BASEresp), ATP production-linked respiration (ATPresp), maximal respiration (MAXresp) and respiratory capacity (RC). Results BASEresp, ATPresp, MAXresp and RC were significantly lower in monocytes of patients with HF compared to NL subjects (BASEresp 2.7 ± 0.7 vs. 5.2 ± 1.6, p<0.05; ATPresp 10.0 ± 0.8 vs. 15.9 ± 1.0, p<0.05; MAXresp 36.5 ± 5.9 vs. 69.3 ± 3.8, p<0.05; RC 26.5 ± 5.5 vs. 53.5 ± 3.5, p<0.05). Conclusions Mitochondrial dysfunction is present in circulating blood monocytes of patients with chronic HF. These findings coupled to those in dogs with HF suggest the possibility that determination of mitochondrial function in peripheral monocytes may identify those patients with HF with cardiac energetic deficiencies. If validated this technique could help illuminate how cardiac energy deprivation relates to disease progression and potentially enable targeted therapies directed at mitochondria dysfunction.

Use of an echocardiographic-based, artificial intelligence system to improve racial disparities in care of patients with valvular heart disease

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Referral for valvular interventions is frequently delayed, and racial disparities in access to care are prominent in the United States. Purpose To assess the effectiveness of an echocardiographic (Echo) – based, artificial intelligence (AI) driven protocol in improving management of patients with severe aortic stenosis (SAS) and severe mitral regurgitation (SMR). Methods From 10/2019 to 11/2022, 126,678 Echo’s (73,453 patients) were screened using a proprietary natural language processing (NLP) system to detect SAS and SMR based on the ACC/AHA guidelines. Aggregated zip code-derived census data and the area deprivation index (ADI) were merged based on each patient’s recorded address at the time of their index Echo. The control group comprised of Echo’s performed 10/2019–2/2020 (prior to implementation of our NLP system) and the intervention group of those between 2/2020–11/2022 (following implementation of NLP). Our AI system uses NLP to detect SAS/SMR from Echo reports and automatically sends a notification to the referring clinician’s inbox with recommendation for referral to appropriate specialist. The endpoint was follow-up defined as the combination of (a) follow-up Echo, (b) follow-up clinic visit with the heart valve (for SAS) or the advanced heart failure clinic (for those with SMR), or (c) follow-up valvular intervention. Results Figure 1 summarizes the sociodemographic and Echo characteristics of the patients, as well as outcomes. Notifications were more likely to be sent out for black patients (OR 2, 1.69–2.34, p<0.001), and those with a lower mean national ADI rank (39.29 vs 42.33, p = 0.001). Time to the combined follow up was improved (74 days vs. 43 days, pre vs. post AI/NLP, p< 0.001) (Figure 1, 2A). Both white and black patients saw an improvement in time to combined endpoint (57 vs 36 days, p = 0.015 for whites, 120 vs 64 days, p = 0.035 for blacks), the improvement being more significant in black patients (Figure 2B). Conclusions An Echo - based, AI/NLP system was helpful in improving overall management of patients with SAS and SMR and in bridging racial disparities. More diverse, multi-site studies are needed to confirm our single-site findings.

(473) Incorporating Palliative Care Services in the Advanced Heart Failure Clinic

(473) Incorporating Palliative Care Services in the Advanced Heart Failure Clinic

The HOPE Clinic: More Than Just a Name Change

“Does advanced heart failure mean that there is no hope for my medical condition?” “Is it true that I not only have heart failure, but advanced heart failure? What does that mean?” These are only a sampling of numerous comments we have received from surveys our advanced heart failure clinic periodically sends out to patients. It is not uncommon when I meet patients for the first time in the office that I see their eyes stare at my white coat reading the label “Advanced Heart Failure.” Thus, from the beginning, we are fighting an uphill battle to help patients and families understand their heart condition. “Advanced Heart Failure” conveys a sense of despair that not much can be done to help them. The truth of the matter is a lot can be done.

A survey-based triage tool to identify patients potentially eligible for referral to an advanced heart failure centre.

Accurate prevalence data for ambulatory advanced heart failure (HF) in European countries remains limited. This study was designed to identify the population of patients potentially eligible for referral for assessment for advanced surgical HF therapies to a National advanced HF and cardiac transplant centre. A survey comprising 13 potential clinical markers of advanced HF was developed, modified from the 'I NEED HELP' tool from the 2018 position statement of the Heart Failure Association of the European Society of Cardiology, and distributed to all HF clinic services (secondary and tertiary units) nationwide. Each HF clinic unit was asked to complete the survey on consecutive patients over a 3month period fulfilling the following three criteria: (i) age <65years; (ii) ejection fraction <40% and (iii) HF of >3months duration. As a comparison, the number of actual referrals to the advanced HF clinic were also audited over a 9month period. In all, 21 of 26 HF clinic units participated in the survey. Across the period of inclusion, 4950 all-comer HF patients were seen across all sites. Of these, 375 (7.5%) fulfilled the inclusion criteria and were surveyed (74.4% male, median age 57years [IQR: 11years]). In total, 246 (66%) of the surveyed patients had ≥1 potential markers for advanced HF, representing just under 5% of the total all-comer HF population seen across the same time period. Of these, 67 patients (27%) had ≥2, 48 (20%) had 3 and 40 (16%) had ≥4 potential markers. The most frequently noted markers were ≥1 HF hospitalization or unscheduled clinic review (56%), intolerance to renin-angiotensin-aldosterone system inhibitors due to hypotension or renal dysfunction (29%) and intolerance to beta-blockers due to hypotension (27%). Almost one-quarter of patients reported NYHA Class III or IV symptoms. During the advanced HF clinic audit, the number of patients actually referred to the advanced HF clinic during the same time period was <5% of this potentially eligible cohort. In this index prospective National survey, approximately 5% of an all-comer routine HF clinic population and two-thirds of a pre-selected HF with reduced EF under 65years cohort were found to have at least one clinical or biochemical marker suggesting advanced or impending advanced HF. Almost one-quarter of patients in this chronic outpatient 'snapshot' population have NYHA III-IV symptoms. This simple one-page triage survey-modified from the 'I NEED HELP' tool-is useful to identify a population potentially eligible for referral to an advanced HF centre for assessment for advanced surgical therapies, thereby aiding resource and service planning.

Economic Impact of Ambulatory Clinical Pharmacists in an Advanced Heart Failure Clinic.

Clinical pharmacists play pivotal roles in multidisciplinary heart failure (HF) teams through the management of HF pharmacotherapy, but no study has examined the economic impact of HF ambulatory clinical pharmacists in an advanced HF clinic. The objective of the study was to evaluate the economic impact of HF ambulatory clinical pharmacist interventions in an advanced HF clinic using a cost-benefit analysis. This prospective observational study detailed HF ambulatory clinical pharmacist interventions over 6 months in an advanced HF clinic in a single-center tertiary teaching hospital. The economic impact of the interventions was estimated based on the indirect cost savings with pharmacist interventions and direct cost savings recommendations. A cost-benefit analysis was performed to assess the cost of delivering the interventions compared with the benefits generated by clinical pharmacists. Results were reported as a benefit-cost ratio and net benefits. HF ambulatory clinical pharmacists made a total of 2,361 provider-accepted interventions over 6 months. Overall, the 3 most common intervention types were medication reconciliation (28.7%), dose change (20.8%), and addition of medication (12.3%). Anticoagulation (21.2%) was the most common intervened class of medication, followed by sodium-glucose cotransporter-2 inhibitor (12.3%) and angiotensin receptor neprilysin inhibitor (9.2%). The total net benefits were $55,553.24 over 6 months and the benefit-cost ratio was 1.55. The addition of cardiology clinical pharmacists to an advanced HF clinic may be financially justified and cost-beneficial.

Heart failure with improved ejection fraction in advanced heart failure clinic

Abstract Objectives The aims of the study were: (1) to determine the pattern of myocardial fibrosis assessed by delayed gadolinium enhancement cardiac MRI (DGE-CMRI) in patients with heart failure improved ejection fraction (HF-iEF) in an advanced heat failure clinic; and (2) to examine the dosage of beta-blocker and angiotensin converting enzyme inhibitor/ angiotensin receptor blockage/angiotensin neprilysin inhibitor (ACE-I/ARB/ARNI) in those patients. Methods HF-iEF was defined as patients with LVEF &amp;gt;40% with previously documented LVEF &amp;lt;35% at baseline. Results Among 312 consecutive patients with HF-rEF who were referred for an advanced HF clinic, 18% (56 patients) had HF-iEF within 12 months after referral. Of these, 84% (47 patients) had non-ischemic cardiomyopathy (CM); complete data on MRI for analysis were available for 25 of these patients (62%). Myocardial scar was found in 52% of patients with nonischemic CM (13 of 25). All patients with nonischemic CM had the myocardial scar of less than 10% of the total LV volume. Mid-wall DGE of the interventricular septum was the most common scar pattern. Among patients with HF-iEF, 36% (20 patients) were referred for heart transplant. Two patients with peripartum related and nonischemic etiologies were listed for heart transplant, and delisted 12 months after. No patient died during 1-year follow up. At 12 months, the mean LVEF change was +27±12%. Improvement of the LVEF to ≥50% occurred in 31 patients (55%). The percentage use of ACE-I/ARB/ARNI and beta-blocker was significantly increased, at 1-year-follow-up. Fourteen percent and 48% of patients achieved target dose of ACE-I/ARB/ARNI and beta-blocker, respectively. There was no significant association between myocardial scar pattern or extent and dosage of medical titration. Conclusions HF-iEF was present in 18% of patients with HF-rEF after 1-year follow-up in advanced heart failure clinic. Mid-wall DGE of the interventricular septum was the most common scar pattern in nonischemic HF-iEF. None of patients with nonischemic HF-iEF had myocardial scar &amp;gt;10% of the total LV volume. Improvement of LVEF to ≥50% occurred in approximately half of the study patients, and led to delisting patients from heart transplant waiting list. The majority of patients had recovery of the LVEF when the target dose of beta-blocker or ACE-I/ARB/ARNI had not been achieved during medical up-titration. Funding Acknowledgement Type of funding source: None

Impact of a multidisciplinary heart failure management program in ambulatory patients with heart failure with reduced ejection fraction referred for advanced heart failure therapy

Abstract Objectives To assess 1-year outcomes of patients with heart failure with reduced ejection fraction (HF-rEF) who referred to a multidisciplinary heart failure (HF) clinic for advanced HF therapy. Methods We studied consecutive 312 ambulatory patients (mean age 51 years, 79% male) with HF-rEF (mean EF 23±8%) who were referred from cardiologists and cardiac surgeons to a multidisciplinary advanced HF clinic. The study patients were divided into 3 groups based on HF/transplant cardiologist evaluation. Group A consisted of 65 patients who were listed for heart transplant (HTx). Group B consisted of 157 patients who were considered as potential HTx candidates but who were too well to be listed for HTx. All patients in this group were not on optimal medical therapy (OMT) for HF-rEF at the time of evaluation. Group C consisted of 90 patients who were not suitable for HTx. Primary outcomes included HTx, left ventricular assist device (LVAD), or death. Outcomes were assessed at baseline and at 1 year after referral Results During the mean follow-up period of 9.6±4.1 months, 88 primary outcomes (28%) occurred (43 deaths (14%), 42 HTxs (14%) and 3 LVAD implants (1%)). Patients in group A, B, and C had a1-year survival of 91%, 90%, and 78%, respectively. At 1-year follow-up, 59%, 3%, and 0% in patients in group A, B, and C underwent HTx. The median waiting time for HTx was 5 months. At 1 year after referral, there was a 20%, 92%, and 63% reduction in HF admission in group A, B, and C, respectively; 44 HF admissions (0.2%/patients) occurred at 1 year after referral, compared with 530 HF admissions (1.7%/patients) 1 year before referral (p&amp;lt;0.001). There was a significant increased rate of β-blocker (BB) use at 1 year (69% vs. 95% receiving BB, p&amp;lt;0.001; and 5% vs. 43% receiving target dose of BB, p&amp;lt;0.001). There was also an increased use of angiotensin converting enzyme inhibitor (ACE-I) /angiotensin receptor blocker (ARB)/ angiotensin receptor Neprilysin inhibitor (ARNI) (68% vs. 88% receiving ACE/ARB/ARNI, p&amp;lt;0.01; and 6% vs. 17% achieving target dose, p&amp;lt;0.01). The increase in utilization of BB and ACE/ARB/ARNI was evident across the 3 groups. LVEF recovery at 1 year occurred in 2%, 28%, and 6% in patients in group A, B, and C. Ten patients in group A (15%) were delisted for clinical improvement. Peak oxygen consumption improved after 1-year referral (13.9 vs. 19.5 ml/kg/min, p&amp;lt;0.01). Conclusions In the contemporary treatment of HF, a multidisciplinary HF clinic led to improved optimal medical therapy (OMT), and an 88% reduction in HF admission in ambulatory patients with HF-rEF. The impact of these benefits was evident across the entire spectrum of HF severity particularly patients who were considered as potential HTx candidates but who were not on OMT (50% of referrals). About a third had LVEF recovery after intensive medical therapy. These findings suggested that OMT and intensive multidisciplinary HF care may prevent overtreatment HTtx. Funding Acknowledgement Type of funding source: None

Shared Care Site To A Destination Therapy (dt) Left Ventricular Assist Device (lvad) Implant Site; A Novel Strategy To Start A Dt Lvad Program

Introduction Left ventricular assist devices have become the standard of care for end-stage heart failure patients over the last decade. Most centers start the DT LVAD program without assessment of the regional need, advanced heart failure clinic, and infrastructure needed to support a DT LVAD program. The shared care model has previously been described where a patient is implanted at a regional center and then returns for complete care at the local heart failure program with similar outcomes. We explore the benefits of a novel model where a center does shared care prior to becoming a DT LVAD center. Hypothesis Benefits of Shared care LVAD site prior to transitioning into a Destination Therapy (DT) LVAD implant site. Methods Deborah Heart and lung center (DHLC) started an advanced heart failure program in 2017. Initially, advanced heart failure patients were referred to regional Destination therapy centers with a shared care model. After the implant, patients received complete care at the shared care site (DHLC). This helped the shared care site identify gaps and establish LVAD complication management services such as GI, neurology, ID, palliative care, nutrition, social work, and case management. Shared care experience lead DHLC to become a certified DT LVAD site by DNV-GL. Results From 4-2017 to 4-2020, 20 patients were implanted as a shared care model. 64% were implanted as intermacs 3 and 36 % were implanted as intermacs 1-2. 80 % of Intermacs 3 patients were discharged home and 65% of Intermacs 1-2 patients were discharged home. Over a 3year period, a total of 65 hospitalizations occurred. There were 16 GI bleeds events in a total of 31% of patients, 23% of patients had CVA events with a total of 5 events, and 5% of patients had driveline infections with 1 event. The mortality rate was 27 % with 6 mortalities in this time period. Currently, 22 patients are being followed as shared care. In 2/2019, DHLC was approved as a DT LVAD site. From 4-2019 to 5-2020, 15 patients have been implanted at DHLC with LVADS. Approximately,100 % of Intermacs 3 patients were discharged to home, and 75% of Intermacs1-2 patients were discharged to home from our LVAD site. 23 patients were hospitalized with 0% CVA events, 20% GI bleed events, and approximately 3 % driveline infections with a mortality rate were 15%. Conclusions There are currently 183 LVAD Implant sites in the US approved by CMS. Despite securing CMS approval, a significant number of sites perform less than 10 LVAD implants per year. Low implant volume has shown to increase adverse outcomes. Our experience indicates that new programs who want to start a DT LVAD program should start with a shared care to DT LVAD model. This model will help establish the infrastructure needed to support the program as well as improving outcomes. Further studies are needed to explore this model.

Intraventricular Flow Patterns in Patients Treated with Left Ventricular Assist Devices.

The success of left ventricular assist device (LVAD) therapy is hampered by complications such as thrombosis and bleeding. Understanding blood flow interactions between the heart and the LVAD might help optimize treatment and decrease complication rates. We hypothesized that LVADs modify shear stresses and blood transit in the left ventricle (LV) by changing flow patterns and that these changes can be characterized using 2D echo color Doppler velocimetry (echo-CDV). We used echo-CDV and custom postprocessing methods to map blood flow inside the LV in patients with ongoing LVAD support (Heartmate II, N = 7). We compared it to healthy controls (N = 20) and patients with dilated cardiomyopathy (DCM, N = 20). We also analyzed intraventricular flow changes during LVAD ramp tests (baseline ± 400 rpm). LVAD support reversed the increase in blood stasis associated with DCM, but it did not reduce intraventricular shear exposure. Within the narrow range studied, the ventricular flow was mostly insensitive to changes in pump speed. Patients with significant aortic insufficiency showed abnormalities in blood stasis and shear indices. Overall, this study suggests that noninvasive flow imaging could potentially be used in combination with standard clinical methods for adjusting LVAD settings to optimize flow transport and minimize stasis on an individual basis.

The Use of Sacubitril/Valsartan in an Advanced Heart Failure Clinic is Associated with Decreased Heart Failure Hospitalizations, Improved Left Ventricular Ejection Fraction and Functional Class

Introduction Sacubitril/valsartan has demonstrated improvement in survival in patients with heart failure (HF) and reduced ejection fraction. However, the population studied in the PARADIGM trial may not reflect the patients managed with optimal medical therapy at an advanced heart failure clinic in North America. Our objective was to evaluate the clinical characteristics and outcomes of patients who were initiated on sacubitril/valsartan and followed by Spectrum Health advanced HF clinic. Methods This retrospective study included 177 patients who were initiated on sacubitril/valsartan at the Spectrum Health advanced HF clinic. Epidemiological, pharmacological, clinical, and echocardiographic information was collected. Ejection fraction (EF), functional class, and hospitalizations were compared prior and 6 months after initiation of sacubitril/valsartan. Statistical significance was considered if p Results Our patients were predominantly male (74.1%) and young (57.4±13.7 years) with a median duration of HF of 21 months. Non-ischemic cardiomyopathy was present in 58% of patients. At the time of initiation of sacubitril/valsartan, 82.7% were receiving ACEi or ARB, 98.1% beta-blocker, 55.8% aldosterone antagonist, 11.5% hydralazine or isosorbide, and 69% had an ICD or CRT device. Follow up after the initiation of sacubitril/valsartan was 17±10 months. Of this cohort 48 patients (27%) discontinued sacubitril/valsartan mainly due to side effects. During the follow-up period, 3 patients (1.7%) were listed and 1 patient (0.6%) received a heart transplant, 10 patients (5.6%) received a LVAD, 1 patient (0.6%) selected for VAD, and 10 patients (5.6%) died. Of the 177 patients, 162 patients received sacubitril/valsartan for at least 6 months and among these patients the frequency of HF hospitalizations decreased after sacubitril/valsartan from 41 to 18 (p Conclusion At our advanced HF clinic, patients who received sacubitril/valsartan for at least 6 months had an improvement in functional capacity, left ventricular ejection fraction and decreased rate of hospitalizations. One in every four patients discontinued sacubitril/valsartan and 14.1% of patients reached the combined outcome of death/LVAD/heart transplant/list transplant/VAD selected, underlining the importance of close follow up in this population.

Education and Decision-Making in Patients and Caregivers Considering Left Ventricular Assist Devices

Purpose Left ventricular assist device (LVAD) is a mainstay of therapy in end-stage heart failure, but presents a challenge in decision-making to patients and caregivers. The aim of this study is to assess patient education and understanding of LVAD therapy. Methods Consecutive candidates for LVAD therapy were enrolled for this study. Patients were excluded if they were unable to participate in baseline testing. Prior to LVAD implant, health literacy was assessed by Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) testing, a word-recognition test of 11 items. Cognitive function was assessed by St. Louis University Mental Status Exam (SLUMS), a brief oral and written exam. LVAD knowledge was assessed by a validated 20-item score. Results 21 patients were enrolled. The median age was 59 years and 62% of the patients were male. Most patients were institution naive, and only 47% had a documented prior advanced heart failure (HF) clinic visit. The majority of patients were on IV inotropes (85.7%) at the time of evaluation and many had indwelling aortic balloon pumps (42.9%). The median time to assessment following formal LVAD education was 1 day. 31% of patients had low health literacy based on REALM-R testing. Median SLUMS scores were in range of mild neurocognitive disorder (22.5; IQR 21, 25) (Fig. 1A). Baseline knowledge check demonstrated a low median score (45/100; IQR 35, 50) (Fig. 1B), and no patient reached a score of >70 (previously described average). Conclusion The majority of referrals for LVAD at our institution are late referrals of critically ill patients. Health literacy and cognitive scores are low in our patient population resulting in low knowledge check scores, despite systematic LVAD education. Patient specific LVAD education should address each patient's individual needs.

Heart Transplantation in Cardiac Amyloidosis: A Ten Year Experience

Purpose Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy associated with poor prognosis. We sought to summarize the outcomes for patients with light chain (AL) or transthyretin (ATTR) CA receiving heart transplantation at our institution and a collaborating institution. Methods This is a retrospective examination of patients with end-stage CA who underwent orthotopic heart transplantation (OHT) at the Cleveland Clinic in Cleveland, Ohio, and with collaboration at Baylor Scott & White Advanced Heart Failure Clinic in Dallas, Texas, from May 2008 to September 2018. Results OHT was performed in 14 cases of CA, twelve at Cleveland Clinic and two at Baylor Scott & White Advanced Heart Failure Clinic. Twelve patients had ATTR (3 wild type, 9 hereditary) and 2 patients AL. Twelve patients have completed one-year follow-up and 100% of patients are alive with a median post-transplant survival of 3 years (range 0.1-10.5 years). Median time from amyloidosis diagnosis to OHT was 16 months (IQR, 9-29 months). Median time awaiting transplant was 5 months (IQR, 1-8 months). Four patients received a heart-multiorgan transplantation: one patient with AL received a kidney and three patients with hereditary ATTR (hATTR) due to the T60A mutation received a liver. One patient with AL underwent autologous stem cell transplantation 6 months after OHT and is stable at 4.2 years follow-up. Six patients with hereditary ATTR due to the V122I mutation underwent isolated OHT; two with long-term follow-up of 7.2 and 10.3 years respectively. Three patients displayed presumed signs of extra-cardiac amyloid involvement post-transplantation: an hATTR V122I patient required spinal stenosis surgery 2 years after transplant, a wild-type ATTR patient required spinal stenosis surgery 10 years after transplant, and an hATTR T60A patient developed chronic diarrhea 9 years after combined heart-liver transplant. No patient had evidence of recurrent amyloid deposition in the cardiac allograft. Conclusion Our experience confirmed that heart transplantation is a viable long-term treatment option for select patients with CA. Post OHT, presumed extra-cardiac involvement of amyloidosis occurred in 3 ATTR patients, but no patients showed re-emergence of CA in their recipient organ.

A Multidisciplinary Team Approach Enhances the Positive Impact of a Heart Failure Community Paramedicine Program

Introduction High risk heart failure (HF) patients with complex clinical and social barriers often do not respond to or qualify for traditional interventions and supportive services. These patients unfortunately fail at home due to a lack of adequate resources. There is a need to provide additional support to this high risk population. A comprehensive approach utilizing a multidisciplinary team in conjunction with Community Paramedicine can benefit this challenging group. The team (HF Nurse Practitioner, HF Nurse Navigator, HF Clinical Social Worker, Community Paramedic, HF Clinic Nurse and ACO Program Manager) meet weekly to review active community paramedic patients. They identify and act upon ongoing barriers that may impact patient success. The purpose of this study is to examine the effectiveness of this diverse team approach in conjunction with a Community Paramedicine Program. A multidisciplinary team approach to Community Paramedicine allows for enhanced communication and better support for high risk heart failure patients. Timely resolution of complex medical and social needs assists with reducing hospital utilization in this group. Method This was a retrospective database research design. Medical records were utilized to assess hospitalization and Emergency Department visit data in 65 patients either actively or formerly enrolled in the Community Paramedicine program. A control group consisting of similar heart failure patients not enrolled in the Community Paramedicine Program was developed for comparison. Results The study data indicates that participants in the Multidisciplinary Community Paramedicine Program had a 53% (p Conclusions A multidisciplinary team approach to Community Paramedicine allows for better identification of medical and social barriers that may impact patient outcomes. This team in collaboration with an Advanced Heart Failure Clinic is successful in reducing overall hospital usage and enhances the positive impact made by a Community Paramedicine Program particularly for high risk heart failure patients. Larger studies are necessary to confirm the benefits found in this study.

Electromagnetic Interference between Subcutaneous ICD and HeartMate II LVAD

Introduction ICDs have been shown to have a significant benefit in reducing sudden cardiac death in patients with systolic heart failure. Additionally, cardiac devices as a bridge to transplant or destination therapy are often used in patients with end stage systolic heart failure. As a result most patients with LVADs also have an ICD. Subcutaneous ICD(S-ICD) was recently introduced into clinical trials to defibrillate ventricular arrhythmias, avoiding drawbacks of transvenous leads. It is therefore not surprising to find complexities arising such as this case of inappropriate S-ICD shock due to electromagnetic interference (EMI) between HeartMate II LVAD and S-ICD. Case Description A 31-year-old woman with a history of postpartum cardiomyopathy (American College of Cardiology stage D) was seen in the advanced heart Failure clinic with complaint of multiple S-ICD shocks over the last few months. The patient reported an implantation of a Boston Scientific S-ICD 7 months and a St. Jude HeartMate II LVAD as destination therapy 4 months prior to the presentation. S-ICD interrogation revealed multiple inappropriate shocks secondary to EMI between the two devices. Since the patient had no documented ventricular arrhythmias or history of ICD therapy prior to LVAD placement, it was decided to turn off the S-ICD and consider a transvenous ICD in the future if she should develop any significant arrhythmias. Conclusion EMI created by LVADs in the presence of an ICD has been previously described but to our knowledge this is the first case reporting EMI between HeartMate II and S-ICD. Multiple different methods have been described to resolve EMI between LVAD and transvenous ICD including “Pseudo” Faraday Cage and “Pan” methods. In cases of non-compatible devices, implantation of the transveous ICD in the contralateral side of LVAD has been also tried successfully, however it is unclear if repositioning the S-ICD pulse generator or the lead can change the vector adequately to avoid EMI. Additionally S-ICDs do not have the ability to engage in anti-tachycardia pacing to prevent shocks which are potentially lethal negative nootropic events in patients with severe LV dysfunction. Consequently, some patients may need transvenous ICD implantation to potentially resolve these issues. As cardiac devices continue to evolve, it is critical for advanced heart failure/ transplant cardiologists and electrophysiologists to understand potential interactions, and make appropriate pre-operative choices to eliminate this potential issue. Image 1: Close proximity of LVAD and S-ICD in our patient which potentially can increase the risk of EMI.

Nurse-led education for heart failure patients in developing countries.

a total of 131 cardiac centre-based nurses and 30 chronic heart failure patients participated in the study in Kuwait. Patients were surveyed a second time 3 to 6 months later, while being followed at an advanced heart failure clinic by dedicated heart failure nurses. the majority of the nurses (80%) had not received heart failure education previously, although they were able to recognise most heart failure symptoms. Significant improvement in patients' knowledge was noted between the initial and follow-up surveys. establishing a dedicated advanced heart failure programme to care for patients in a developing country can result in significant improvement in disease awareness and self-care behaviours when led by well-trained heart failure nurses. More research is needed to determine if these findings are shared by other countries in the Middle-East and other developing countries.

Abstract 262: Preferences for Primary versus Specialty Palliative Care Among Patients With Heart Failure

Background: More than 5 million people in the USA suffer from heart failure (HF). Palliative care (PC) is both a clinical subspecialty and overall approach to care that focuses on promoting seriously ill patients and their family’s quality of life. PC takes several forms, including consultation by a PC specialist, or attention to palliative domains by a non-PC specialist (aka “primary” PC). Despite guidelines calling for the integration of PC in HF, specialty PC remains underutilized. Patient preferences regarding primary vs specialty PC are unknown. Objective: To identify patient knowledge and perceptions regarding how primary and specialty PC could complement usual HF management, as well as barriers preventing PC utilization. Methods: We recruited individuals with NYHA class II-IV HF from general medicine wards and an outpatient advanced HF clinic, both at an academic quaternary care hospital. We conducted semi-structured interviews addressing: (1) patient-perceived physical, emotional, social, and decision-making needs; (2) perception, knowledge, and preferences regarding PC; (3) barriers and facilitators to PC. To understand patient preferences regarding primary vs specialty PC, in the interview guide, we conceptualized PC into 5 domains: physical, emotional, spiritual and social aspects of care, and advance care planning. For each domain, participants discussed unmet needs, and preferences about whether the needs would be best met by their existing cardiology team or a PC specialist. Two investigators independently analyzed data using template analysis, an inductive/deductive qualitative technique. Results: We interviewed 28 patients; 82% were white, 61% were &gt;60 years, and 64% were male. 43% of participants had ejection fractions &lt;30%, and 64% were of NYHA classes III or IV. Symptom burden was high and a source of dissatisfaction; yet, few believed that their disease management was suboptimal, often citing a sense of resignation that symptoms are inevitable in HF. We heard mixed and often incorrect understandings of PC (and its distinction from hospice). Once misperceptions of PC were corrected, respondents expressed variable preferences for specialty vs. primary PC. Proponents of primary PC cited trust and rapport in their existing clinicians, HF-specific expertise, convenience, and cost. Alternatively, participants preferring specialty PC involvement cited expertise in symptom management, addressing caregiver concerns, reduced time constraints, and a comprehensive non-HF-exclusive approach to care. Conclusion: We frequently identified limited and often incorrect understanding of PC. Though once corrected, patients articulated variable preferences for primary vs. specialty PC integration into their existing HF care. Research is needed to identify means of increasing primary and specialty PC delivery in HF in a manner that reflects patient preferences.

Emerging Data Support Benefits of Yoga for Patients With Heart Disease.

Diaphragmatic breathing techniques that 1 patient learned during a yoga-based cardiac rehabilitation class helped him overcome the stress and anxiety he often felt in the waiting room of his cardiologist’s office. The patient, like many seen by Sara Chambers, RN, BSN, assistant nurse manager in Cardiac Rehabilitation at Palm Beach Gardens Medical Center, said yoga helped him learn valuable coping techniques he uses in daily life. “Cardiac patients in particular tend to have a lot of stress,” said Chambers, who is is among the >20 million, or 9.5%, of US individuals who practice yoga, according to the 2012 National Health Interview Survey. Now, an emerging body of evidence suggests that yoga, which combines breathing exercises, strengthening and stretching poses, and relaxation techniques, can be beneficial for individuals with heart conditions or other chronic diseases. It seems to have comparable safety to other forms of exercise. “There are multiple studies that [suggest] that regular yoga practice with breathing exercises can increase lung volume, decrease heart rate and blood pressure, help regulate the parasympathetic and sympathetic nervous systems, lower anxiety, and physical endurance,” said Chambers. Although many forms of exercise can be beneficial for patients with chronic diseases, the unique aspect of yoga “is the strong focus on breathing technique and …

Ability to Achieve Target Doses of an Evidence-based Heart Failure Treatment Regimen in an Advanced Heart Failure Clinic at a Tertiary Care Facility

Ability to Achieve Target Doses of an Evidence-based Heart Failure Treatment Regimen in an Advanced Heart Failure Clinic at a Tertiary Care Facility

Integrated Outpatient Care in Advanced Heart Failure: the Beehive Person-Centered Model

Rationale: Cardiovascular disease (CVD) is one of the leading causes of chronic care needs. According to the World Health Organization, by 2030 the number of people dying from CVD is expected to reach 23.3 million. Heart failure is a chronic, progressive, incurable condition which poses a substantial physical, psychological, spiritual and social burden on patients, families as well as formal and informal carers. The complex needs of these patients require the planning and implementation of a new, revisited approach to disease management. Methods: In Trieste, Italy, the long-standing integrated outpatient approach to care has been recently integrated by a dedicated Advanced Heart Failure Clinic (AHFC) for the identification of holistic needs and the provision of multidisciplinary, multidimensional supportive and palliative care to patients with advanced HF and their families. Emphasis is being laid not only on the diseased care recipient but on the ‘person’ who attends and is being attended to, who empowers and is being empowered by through an integrated process of care.Results: The integration of outpatient care services is challenging for all the stakeholders involved. A multidisciplinary, multidimensional, person-centered integrated model of care (the beehive person-centered model) might improve heart failure awareness and knowledge and would help structure better territorial outpatient pathways for patients and families, while enhancing formal and informal carers’ individual roles and general wellbeing.Discussion: The need for interconnectedness in the Beehive Person-Centered Model requires for all stakeholders to view each other as symmetrical allies, which may be utopist at best. Flexibility to adapt to individual, organizational and environmental changes may pose challenges to the long-term sustainability of integrated pathways and bring about conforming behaviors rather than proactive ones, which may jeopardize individual accountability. However, an empowered team may provide short and long term benefits to its members such as clarity of vision, greater self-awareness, self-monitoring and adapatability to changes. Conclusions: A Beehive Person-Centered Model of integrated, multidisciplinary and multidimensional evidence and values-based care may prove useful to reconcile clinical, emotional, spiritual and social needs of all stakeholders involved in the cure/care process and ensure sustainable, efficient and effective long-term care. Further qualitative/quantitative research is needed to confirm its efficacy and effectiveness and cultural transferability.