Left Ventricular Assist Device Deactivation Research Articles

(1181) - Innovative Technique for Left Ventricular Assist Device Deactivation: A Description Case

(1181) - Innovative Technique for Left Ventricular Assist Device Deactivation: A Description Case

The Complex Ethical and Moral Experience of Left Ventricular Assist Device Deactivation

The left ventricular assist device (LVAD) is a fully implantable cardiac replacement device that can complicate the process of dying. We present a case of a patient who attempted to deactivate the LVAD without the support of his medical team. This action was understood as a “suicide attempt” though when the patient was later felt to be dying, LVAD deactivation proceeded without reference to psychiatric illness. To understand this case, we discuss the ethics of LVAD deactivation in the dying process. We then explore the experience of clinicians and the public encountering this unique technology across clinical contexts. We herein present a novel and possibly controversial analysis of the moral complexities of LVAD deactivation and suggest that clinicians be transparent about these complexities with patients and families.

Clinical Protocol for Left Ventricular Assist Device Deactivation at End of Life.

As patients live longer with left ventricular assist device (LVAD) support, many will either suffer an acute event or develop a gradual, progressive disease that results in a terminal prognosis. At the end-of-life, patients, and more often, their families, will be faced with the decision to deactivate the LVAD to allow natural death. The process of LVAD deactivation carries some distinct features that distinguish it from withdrawal of other forms of life-sustaining medical technology: multidisciplinary collaboration is paramount; prognosis after deactivation is short, typically minutes-hours; and premedication doses of symptom-focused medications are typically higher than other situations involving withdrawal of life-sustaining medical technologies given the precipitous decline in cardiac output following LVAD deactivation. In this Case Discussion, we introduce the complexity of planned in-hospital LVAD deactivation through a clinical case, share our detailed institutional checklist and order set for LVAD deactivation, and broach multidisciplinary clinical protocol development processes.

Left ventricular assist device deactivation following cardiac recovery and pump thrombosis

Left ventricular assist devices (LVADs) have become an increasingly important component of the management of severe heart failure not only as bridge therapy to eventual orthotopic heart transplantation, but also as destination therapy. Timely diagnosis and management of device complications are of vital importance. Rarely, LVAD placement can result in cardiac recovery that may necessitate device removal. While there are reports of minimally invasive LVAD deactivation, there are currently no guidelines for device extraction or deactivation in the setting of cardiac recovery. This is a case of both cardiac recovery and pump thrombosis following LVAD implantation, managed with device inactivation and driveline excision.

Intraoperative Transesophageal Echocardiography Examination for Percutaneous Left Ventricular Assist Device Deactivation.

Intraoperative Transesophageal Echocardiography Examination for Percutaneous Left Ventricular Assist Device Deactivation.

Is Left Ventricular Assist Device Deactivation Ethically Acceptable? A Study on the Euthanasia Debate

In the last decades, new technologies have improved the survival of patients affected by chronic illnesses. Among them, left ventricular assist device (LVAD) has represented a viable solution for patients with advanced heart failure (HF). Even though the LVAD prolongs life expectancy, patients’ vulnerability generally increases during follow up and patients’ request for the device withdrawal might occur. Such a request raises some ethical concerns in that it directly hastens the patient’s death. Hence, in order to assess the ethical acceptability of LVAD withdrawal, we analyse and examine an ethical argument, widely adopted in the literature, that we call the “descriptive approach”, which consists in giving a definition of life-sustaining treatment to evaluate the ethical acceptability of treatment withdrawal. Focusing attention on LVAD, we show criticisms of this perspective. Finally, we assess every patient’s request of LVAD withdrawal through a prescriptive approach, which finds its roots in the criterion of proportionality.

Percutaneous Deactivation of Left Ventricular Assist Devices

Left ventricular assist device (LVAD) deactivation may be considered in cases of left ventricular recovery, pump thrombosis, infection, and end-of-life palliation. Surgical pump explantation remains the principal method, but percutaneous deactivation presents a safe and effective alternative. We have developed a formal program for percutaneous LVAD deactivation within our advanced heart failure program including patient selection criteria, preprocedure testing, a procedural algorithm, and a postprocedure care plan. Patient selection for percutaneous LVAD deactivation required review by an interdisciplinary heart transplant team including reason for deactivation, cardiac function, surgical risk, and patient preference. All candidates underwent LVAD ramp studies with both transthoracic echocardiography and right heart catheterization assessment. Deactivation was performed under general anesthesia with transesophageal echocardiography guidance. Three Amplatzer Vascular Plug IIs (Abbott, St. Paul, MN) were deployed in the LVAD outflow cannula with the proximal edge of the third plug aligned with the aortic anastomosis of the graft as guided by angiography and 3-dimensional transesophageal echocardiography. In a separate procedure, the LVAD drive line was transected below the skin, which was closed surgically over the driveline stump. Anticoagulation was continued for at least 3 months. Since initiation in January 2017, our program has performed 7 percutaneous LVAD deactivation procedures. All procedures have been successful, 5 of the patients remain medically managed, and 2 have proceeded to heart transplant. Percutaneous LVAD deactivation provides an alternative to surgical explantation. A percutaneous LVAD deactivation program is an important component of an advanced heart failure program.

TCT-85 Minimally Invasive Catheter-Based Deactivation of Left Ventricular Device Without Surgical Explantation

Surgical left ventricular assist device (LVAD) explantation remains the main method for device deactivation. However, such reoperation in patients with advanced cardiac disease carries significant potential risks. The role of a percutaneous LVAD deactivation program, including patient selection and

TCT-176 Catheter based percutaneous left ventricular assist device deactivation: A case series from a Tertiary care center

TCT-176 Catheter based percutaneous left ventricular assist device deactivation: A case series from a Tertiary care center

Percutaneous Deactivation of Ventricular Assist Device: A Case Series from a Tertiary Care Center

Introduction Left ventricular assist device (LVAD) deactivation is considered in certain situations e.g. myocardial recovery, device complication such as pump thrombosis or drive line infection. Surgical pump explantation remains the main method for device deactivation, however it carries its own risks and complications. Aim To assess the feasibility and safety of percutaneous device deactivation. Methods retrospective observational case series of all patients underwent percutaneous device deactivation using Amplatzer Vascular Plug II (AVP II) (St. Jude Medical, St. Paul, Minn) at our institute. Results A total of 4 patients underwent percutaneous LVAD deactivation between August 2017 and March 2018. The 1st patient was a 68 y.o male who underwent LVAD placement with HeartWare HVAD (HeartWare, Inc., Framingham, MA) for ischemic cardiomyopathy (ICMP). He presented in August 2017 with significant pump thrombosis and recurrent TIAs. Given his prohibited surgical risk for a repeat sternotomy, the decision was made to proceed with percutaneous deactivation of his LVAD using two 14 mm AVP II placed at the LVAD outflow graft at each end. Two months later, he underwent successful heart transplant and he continued to do well since then. The 2nd patient was a 35 y.o male with a history of non-ICMP. He underwent placement of Heartmate II (Thoratec Corp., Pleasanton, CA) in November 2014 which was complicated with pump thrombosis requiring pump exchange in March 2017. He presented again in November 2017 with a recurrent pump thrombosis. Given recovery of his cardiac function and patient's request to avoid further surgery, the device was deactivated percutaneously. This was achieved using a 16 mm AVP proximally and a 18 mm distally to the outflow graft. The 3rd patient was a 53 y.o male with a history of non-ICMP s/p HeartWare HVAD placement in October 2017. Given the recovery of his cardiac function, he presented in February 2018 for device deactivation using two 14 mm APV II at the 2 ends with another 12 mm AVP II at mid segment of the outflow graft. The 4th patient was a 57 y.o female with non-ICMP s/p Heartmate III placement in March 2017. She was complicated with recurrent GI bleed secondary to the chronic anticoagulation use. Given this reason along with cardiac recovery, decision was to proceed with device activation percutaneously using two 18 mm AVP at the distal end with another 16 mm AVP II at the proximal end of the outflow graft. The procedure was successful in all the 4 patients, and they continued on anticoagulation afterwards. See Table 1 Conclusion Percutaneous device deactivation is safe and a feasible approach for all different types of LVAD.

End of Life with Left Ventricular Assist Device in Both Bridge to Transplant and Destination Therapy.

The difference of end-of-life care for left ventricular assist device (LVAD) patients, between destination therapy (DT) and bridge to transplant (BTT), and the effect of palliative care in this population remain unknown. The primary outcomes of this retrospective cohort study were the place of death, do-not-resuscitate (DNR) order, palliative care consultation in the last month, and hospice enrollment. Secondary outcomes were time on the LVAD, life-sustaining treatment in the last week of life, LVAD deactivation, and clinical trajectory. Eighty-nine patients who newly underwent LVAD therapy between 2010 and 2016 and died before May 2017 were divided into DT (59) and BTT (30). At death, BTT patients (61.1 ± 8.9 years) were significantly younger (p = 0.046) than DT patients (65.8 ± 12.9 years). Median (25th-75th percentile) time on LVAD was significantly shorter (p = 0.042) in BTT (152 days, 41.3-375.8) than in DT (358 days, 64-892), but the Kaplan-Meier curves were not significantly different (p = 0.055). The place of death (p = 0.092), DNR order (DT; 70.2%, BTT; 76.7%, p = 0.52), palliative care consultation in the last month (DT; 57.1% and BTT; 41.6%, p = 0.22), and hospice enrollment (DT; 8.5%, BTT; 10.0%, p = 1.0), as well as any of secondary outcomes, were not significantly different between groups. After January 2014, palliative care consultation in the last month increased significantly from 14.2% to 78.9% (p < 0.001), and death in intensive care unit decreased significantly (from 79.4% to 52.8%, p = 0.024) with less frequent mechanical ventilation (from 71.4% to 50.0%, p = 0.047) and renal replacement therapy (42.9% to 19.2%, p = 0.017). The clinical course of deceased LVAD patients, circumstances, and treatments at the end of life did not differ significantly between the BTT and DT groups. Palliative care consult seemed associated with less resource utilization. Palliative care team should get involved in the care of LVAD patients, not only for DT but also for BTT.

Matters to address prior to introducing new life support technology in Japan: three serious ethical concerns related to the use of left ventricular assist devices as destination therapy and suggested policies to deal with them

BackgroundDestination therapy (DT) is the permanent implantation of a left ventricular assist device (LVAD) in patients with end-stage, severe heart failure who are ineligible for heart transplantation. DT improves both the quality of life and prognosis of patients with end-stage heart failure. However, there are also downsides to DT such as life-threatening complications and the potential for the patient to live beyond their desired length of life following such major complications. Because of deeply ingrained cultural and religious beliefs regarding death and the sanctity of life, Japanese society may not be ready to make changes needed to enable patients to have LVADs deactivated under certain circumstances to avoid needless suffering.Main textWestern ethical views that permit LVAD deactivation based mainly on respect for autonomy and dignity have not been accepted thus far in Japan and are unlikely to be accepted, given the current Japanese culture and traditional values. Some healthcare professionals might regard patients as ineligible for DT unless they have prepared advance directives. If this were to happen, the right to prepare an advance directive would instead become an obligation to do so. Furthermore, patient selection for DT poses another ethical issue. Given the predominant sanctity of life principle and lack of cost-consciousness regarding medical expenses, medically appropriate exclusion criteria would be ignored and DT could be applied to various patients, including very old patients, the demented, or even patients in persistent vegetative states, through on-site judgment.ConclusionThere is an urgent need for Japan to establish and enact a basic act for patient rights. The act should include: respect for a patient’s right to self-determination; the right to refuse unwanted treatment; the right to prepare legally binding advance directives; the right to decline to prepare such directives; and access to nationally insured healthcare. It should enable those concerned with patient care involving DT to seek ethical advice from ethics committees. Furthermore, it should state that healthcare professionals involved in the discontinuation of life support in a proper manner are immune to any legal action and that they have the right to conscientiously object to LVAD deactivation.

Deactivation of Left Ventricular Assist Devices: Differing Perspectives of Cardiology and Hospice/Palliative Medicine Clinicians

BackgroundBeliefs around deactivation of a left ventricular assist device (LVAD) vary substantially among clinicians, institutions, and patients. Therefore, we sought to understand perspectives regarding LVAD deactivation among cardiology and hospice/palliative medicine (HPM) clinicians. Methods and ResultsWe administered a 41-item survey via electronic mail to members of 3 cardiology and 1 HPM professional societies. A convergent parallel mixed-methods design was used. From October through November 2011, 7168 individuals were sent the survey and 440 responded. Three domains emerged: (1) LVAD as a life-sustaining therapy; (2) complexities of the process of LVAD deactivation; and (3) legal and ethical considerations of LVAD deactivation. Most respondents (cardiology 92%; HPM 81%; P = .15) believed that an LVAD is a life-sustaining treatment for patients with advanced heart failure; however, 60% of cardiology vs 2% of HPM clinicians believed a patient should be imminently dying to deactivate an LVAD (P < .001). Additionally, 87% of cardiology vs 100% of HPM clinicians believed the cause of death following LVAD deactivation was from underlying disease (P < .001), with 13% of cardiology clinicians considering it to be a form of euthanasia or physician-assisted suicide. ConclusionCardiology and HPM clinicians have differing perspectives regarding LVAD deactivation. Bridging the gaps and engaging in dialog between these 2 specialties is a critical first step in creating a more cohesive approach to care for LVAD patients.

Dying With a Left Ventricular Assist Device as Destination Therapy.

Despite the ability of left ventricular assist device as destination therapy (DT-LVAD) to prolong survival for many patients with advanced heart failure, little is known about the eventual end-of-life care that patients with DT-LVAD receive. All patients undergoing DT-LVAD at the Mayo Clinic in Rochester, Minnesota, from January 1, 2007, to September 30, 2014, who subsequently died before July 1, 2015, were included. Information about end-of-life care was obtained from documentation in the electronic medical record. Of 89 patients who died with a DT-LVAD, the median (25th-75th percentile) time from left ventricular assist device implantation to death was 14 (4-31) months. The most common causes of death were multiorgan failure (26%), hemorrhagic stroke (24%), and progressive heart failure (21%). Nearly half (46%) of the patients saw palliative care within 1 month before death; however, only 13 (15%) patients enrolled in hospice a median 11 (range 1-315) days before death. Most patients (78%) died in the hospital, of which 88% died in the intensive care unit. In total, 49 patients had their left ventricular assist device deactivated before death, with all but 3 undergoing deactivation in the hospital. Most patients died within an hour of left ventricular assist device deactivation and all within 26 hours. In contrast to the general heart failure population, most patients with DT-LVAD die in the hospital and few use hospice. Further work is needed to understand these differences and to determine whether patients with DT-LVAD are receiving optimal end-of-life care.

Hospice and Palliative Medicine Clinicians' Attitudes Towards Left Ventricular Assist Device Deactivation (S793)

worsened disability (adjustedHR 1.43, 95%CI 1.22-1.67) and death (adjusted HR 1.59, 95% CI 1.28-1.96). Conclusions. Over one in five older adults in the US experiences dyspnea. Older adults with dyspnea are about 50% more likely to develop new or worsened disability or die during the next 4 years. Implications forResearch,Policy, orPractice. There is no perfect test for dyspnea. As with pain, asking about dyspnea should be a routine component of care for older adults.

Ethical Challenges of Deactivation of Cardiac Devices in Advanced Heart Failure

More than 23 million adults worldwide have heart failure (HF). Although survival after heart failure diagnosis has improved over time, mortality from heart failure remains high. At the end of life, the chronic HF patient often becomes increasingly symptomatic, and may have other life-limiting comorbidities as well. Multiple trials have shown a clear mortality benefit with the use of implantable cardioverter defibrillators (ICDs) in patients with cardiomyopathy and ventricular arrhythmia. However, patients who have an ICD may be denied the chance of a sudden cardiac death, and instead are committed to a slower terminal decline, with frequent DC shocks that can be painful and decrease the quality of life, greatly contributing to their distress and that of their families during this period. While patients with ICDs are routinely counseled with regard to the benefits of ICDs, they have a poor understanding of the options for device deactivation and related ethical and legal implications. Deactivating an ICD or not performing a generator change is both legal and ethical, and is supported by guidelines from both sides of the Atlantic. Patient autonomy is paramount, and no patient is committed to any therapy that they no longer wish to receive. Left ventricular assist devices (LVADs) were initially used as bridge in patients awaiting heart transplantation, but they are currently implanted as destination therapy (DT) in patients with end-stage heart failure who have failed to respond to optimal medical therapy and who are ineligible for cardiac transplantation. The decision-making process for initiation and deactivation of LVAD is becoming more and more ethically and clinically challenging, particularly for elderly patients.

Artificial heart and assist devices: Directions, needs, costs, societal and ethical issues

Beliefs around deactivation of a left ventricular assist device (LVAD) vary substantially among clinicians, institutions, and patients. Therefore, we sought to understand perspectives regarding LVAD deactivation among cardiology and hospice/palliative medicine (HPM) clinicians.We administered a 41-item survey via electronic mail to members of 3 cardiology and 1 HPM professional societies. A convergent parallel mixed-methods design was used. From October through November 2011, 7168 individuals were sent the survey and 440 responded. Three domains emerged: (1) LVAD as a life-sustaining therapy; (2) complexities of the process of LVAD deactivation; and (3) legal and ethical considerations of LVAD deactivation. Most respondents (cardiology 92%; HPM 81%; P = .15) believed that an LVAD is a life-sustaining treatment for patients with advanced heart failure; however, 60% of cardiology vs 2% of HPM clinicians believed a patient should be imminently dying to deactivate an LVAD (P < .001). Additionally, 87% of cardiology vs 100% of HPM clinicians believed the cause of death following LVAD deactivation was from underlying disease (P < .001), with 13% of cardiology clinicians considering it to be a form of euthanasia or physician-assisted suicide.Cardiology and HPM clinicians have differing perspectives regarding LVAD deactivation. Bridging the gaps and engaging in dialog between these 2 specialties is a critical first step in creating a more cohesive approach to care for LVAD patients.