Left Ventricular Assist Device Recipients Research Articles

Performance of risk scores in predicting major bleeding in left ventricular assist device recipients: a comparative external validation

BackgroundImplantation of a left ventricular assist device (LVAD) is a crucial therapeutic option for selected end-stage heart failure patients. However, major bleeding (MB) complications postimplantation are a significant concern. ObjectivesWe evaluated current risk scores’ predictive accuracy for MB in LVAD recipients. MethodsWe conducted an observational, single-center study of LVAD recipients (HeartWare or HeartMate-3, November 2010-December 2022) in the Netherlands. The primary outcome was the time to first post-LVAD MB (according to the International Society on Thrombosis and Haemostasis [ISTH] and Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS], and INTERMACS combined with intracranial bleeding [INTERMACS+] criteria). Mortality prior to MB was considered a competing event. Discrimination (C-statistic) and calibration were evaluated for HAS-BLED, HEMORR2HAGES, Anticoagulation and Risk Factors in Atrial Fibrillation, Outpatient Bleeding Risk Index, VTE-BLEED, AF-BLEED, and Utah Bleeding Risk Score (UBRS). ResultsOne hundred four patients were included (median age, 64 years; female, 20.2%; HeartWare, 90.4%; HeartMate-3, 9.6%). The cumulative MB incidence was 75.7% (95% CI 65.5%-85.9%) by ISTH and INTERMACS+ criteria and 67.0% (95% CI 56.0%-78.0%) per INTERMACS criteria over a median event-free follow-up time of 1916 days (range, 59-4521). All scores had poor discriminative ability on their intended prediction timeframe. Cumulative area under the receiving operator characteristic curve ranged from 0.49 (95% CI 0.35-0.63, VTE-BLEED) to 0.56 (95% CI 0.47-0.65, UBRS) according to ISTH and INTERMACS+ criteria and from 0.48 (95% CI 0.40-0.56, Anticoagulation and Risk Factors in Atrial Fibrillation) to 0.56 (95% CI 0.47-0.65, UBRS) per INTERMACS criteria. All models showed poor calibration, largely underestimating MB risk. ConclusionCurrent bleeding risk scores exhibit inadequate predictive accuracy for LVAD recipients. There is a need for an accurate risk score to identify LVAD patients at high risk of MB who may benefit from patient-tailored antithrombotic therapy.

Evaluation of the Hemocompatibility of the Direct Oral Anticoagulant Apixaban in Left Ventricular Assist Devices (DOAC LVAD) Study

BackgroundPatients receiving left ventricular assist device (LVAD) support require long-term anticoagulation to reduce the risk of thromboembolic complications. Apixaban is a direct oral anticoagulant that has become first-line therapy; however, its safety in LVAD recipients has not been well described. ObjectivesThis study sought to investigate whether, in patients with a fully magnetically levitated LVAD, treatment with apixaban would be feasible and comparable with respect to safety and freedom from the primary composite outcome of death or major hemocompatibility-related adverse events (HRAEs) (stroke, device thrombosis, major bleeding, aortic root thrombus, and arterial non–central nervous system thromboembolism) as compared with treatment with warfarin. MethodsThe DOAC LVAD (Evaluation of the Hemocompatibility of the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices) trial was a phase 2, open label trial of LVAD recipients randomized 1:1 to either apixaban twice daily or warfarin therapy. All patients were required to take low-dose aspirin. Patients were followed up for 24 weeks to evaluate the primary composite outcome. ResultsA total of 30 patients were randomized: 14 to warfarin and 16 to apixaban. The median patient age was 60 years (Q1-Q3: 52-71 years), and 47% were Black patients. The median time from LVAD implantation to randomization was 115 days (Q1-Q3: 56-859 days). At 24 weeks, the primary composite outcome occurred in no patients receiving apixaban and in 2 patients (14%) receiving warfarin (P = 0.12); these 2 patients experienced major bleeding from gastrointestinal sources. ConclusionsAnticoagulation with apixaban was feasible in patients with an LVAD without an excess of HRAEs or deaths. This study informs future pivotal clinical trials evaluating the safety and efficacy of apixaban in LVAD recipients. (Evaluation of the Hemocompatibility of the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices [DOAC LVAD]; NCT04865978)

(576) - Assessment of Platelet Response to Aspirin Therapy and Hemocompatibility-Related Adverse Events in HeartMate 3 Left Ventricular Assist Device Recipients

(576) - Assessment of Platelet Response to Aspirin Therapy and Hemocompatibility-Related Adverse Events in HeartMate 3 Left Ventricular Assist Device Recipients

(811) - Left Ventricular Assist Device Recipients with a History of Cardiovascular Disease or Cardiothoracic Surgery Have Increased Mortality

(811) - Left Ventricular Assist Device Recipients with a History of Cardiovascular Disease or Cardiothoracic Surgery Have Increased Mortality

Multicenter evaluation of left ventricular assist device implantation with or without ECMO bridge in cardiogenic shock.

The efficacy of extracorporeal membrane oxygenation (ECMO) as a bridge to left ventricular assist device (LVAD) remains unclear, and recipients of the more contemporary HeartMate 3 (HM3) LVAD are not well represented in previous studies. We therefore undertook a multicenter, retrospective study of this population. INTERMACS 1 LVAD recipients from five U.S. centers were included. In-hospital and one-year outcomes were recorded. The primary outcome was the overall mortality hazard comparing ECMO versus non-ECMO patients by propensity-weighted survival analysis. Secondary outcomes included survival by LVAD type, as well as postoperative and one-year outcomes. One hundred and twenty-seven patients were included; 24 received ECMO as a bridge to LVAD. Mortality was higher in patients bridged with ECMO in the primary analysis (HR 3.22 [95%CI 1.06-9.77], p = 0.039). Right ventricular assist device was more common in the ECMO group (ECMO: 54.2% vs non-ECMO: 11.7%, p < 0.001). Ischemic stroke was higher at one year in the ECMO group (ECMO: 25.0% vs non-ECMO: 4.9%, p = 0.006). Among the study cohort, one-year mortality was lower in HM3 than in HeartMate II (HMII) or HeartWare HVAD (10.5% vs 46.9% vs 31.6%, respectively; p < 0.001) recipients. Pump thrombosis at one year was lower in HM3 than in HMII or HVAD (1.8% vs 16.1% vs 16.2%, respectively; p = 0.026) recipients. Higher mortality was observed with ECMO as a bridge to LVAD, likely due to higher acuity illness, yet acceptable one-year survival was seen compared with historical rates. The receipt of the HM3 was associated with improved survival compared with older generation devices.

Kidney Function Trajectories and Right Heart Failure Following LVAD Implantation.

Preoperative kidney dysfunction is a risk factor for right heart failure (RHF) after implantation of a left ventricular assist device (LVAD). However, characteristic kidney function trajectories before and after post-LVAD RHF are uncertain, so we investigated this. We identified individuals who received primary continuous-flow LVAD implantation from July 1, 2014 to December 31, 2017 in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) data set. Incident RHF was ascertained using the INTERMACS definition at 1 and 3 months and classified as transient or persistent. Kidney function trajectories before and after RHF onset, and relationships of baseline kidney function with RHF risk at the different time points, were assessed. We identified 8076 LVAD recipients who met inclusion criteria. Incident RHF was present at 1 month in 26.4%. There were 4850 individuals with follow-up at 3 months, with incident RHF in 4.2%. Kidney function trajectories differed from pre-LVAD implantation to 1-month follow-up by RHF category, with those developing persistent RHF having no improvement in baseline kidney function. For trajectories before the 3-month RHF ascertainment time, the shape was similar for those with and without RHF, with lower estimated glomerular filtration rate levels among those who developed RHF. Baseline estimated glomerular filtration rate levels below the normal range were associated with higher risk of RHF at 1 and 3 months. In LVAD recipients, preimplantation kidney function and subsequent kidney function trajectories differed substantially by RHF at 1 and 3 months postimplantation, even after adjustment for several confounders. This may demonstrate bidirectional associations between kidney function and right ventricular function in LVAD recipients.

Early Postoperative Cardiac Rehabilitation in LVAD Patients: A Case Report

This study emphasizes the crucial role of early mobilization and proactive physical therapy for individuals undergoing left ventricular assist device (LVAD) therapy in the context of chronic or end-stage heart failure. Given the intricate medical complexities and prolonged hospitalizations inherent in this patient cohort, specialized cardiac rehabilitation (CR) strategies emerge as indispensable components in cardiovascular medicine. Detailed herein is a case study featuring a 62-year-old male patient who underwent LVAD implantation and participated in a 7-week cardiac rehabilitation program. The observed outcomes revealed substantial improvements in exercise capacity and muscle strength, assessed through standardized physical assessments. Importantly, echocardiographic evaluation demonstrated no adverse effects on left ventricular function. This case underscores the pivotal significance of early rehabilitation intervention during the postoperative phase, particularly in patients exhibiting stable vital signs and hemodynamics. The findings contribute to the refinement of tailored rehabilitation approaches for LVAD recipients, thereby fostering enhanced clinical outcomes and an elevated quality of life in this specialized patient population. The study underscores the critical importance of implementing early rehabilitation strategies in the holistic care paradigm for LVAD recipients, with potential implications for optimizing therapeutic protocols and improving long-term patient outcomes in the field of cardiovascular rehabilitation.

Epidemiology and Risk Factors for Nosocomial Infections in Left Ventricular Assist Device Recipients.

Left ventricular assist devices (LVADs) have been increasingly used as a valid option to improve the prognosis and reduce the symptoms of end-stage heart failure. However, long-term complications, mostly infections and coagulation disorders, are frequent. We described the epidemiology and risk factors for nosocomial infections (NIs) in a cohort of adult patients who underwent continuous-flow LVAD implant between January 2010 and December 2017 in Turin, Italy. Secondary outcomes were the prevalence of multidrug-resistant (MDR) bacteria and mortality. Results: Overall, 64 LVADs were implanted. A total of 32 (50%) patients experienced at least one episode of NI, with a total of 46 infectious events. VAD-related infections occurred in 22 patients (68.8%). Non VAD-related NIs occurred in 12 patients (37.5%), mainly low respiratory tract infections. Length of intensive care unit admission was a risk factor for NI (OR 1.224, 95%CI; 1.049, 1.429). Gram-negative bacilli were responsible for 58.8% of VAD-related infections and 79.5% of non-VAD related infections. In sixteen patients (50%), at least one episode of infection was related to an MDR strain. INTERMACS class and length of MV were independent risk factors for NIs by MDR strains (respectively, OR 2.12, 95%CI: 1.08, 6.80; p = 0.02 and OR 1.46, 95%CI: 1.07, 5.52, p = 0.047). In-hospital mortality was 6.3%. No differences in mortality were observed between infected and non-infected patients (p = 0.61) even when caused by MDR strains (p = 0.143). Conclusion: the rate of nosocomial infections in LVAD patients is associated with the length of ICU admission, and the etiology of nosocomial infection after LVAD implant is mainly due to GNB, including a high rate of MDR strains, especially KPC-KP and MDR PA.

Improving the Prediction of 1 Year Right Ventricular Failure After Left Ventricular Assist Device Implantation.

Previous predictive models for postimplant right heart failure (RHF) following left ventricular assist device (LVAD) implantation have demonstrated limited performance on validation datasets and are susceptible to overfitting. Thus, the objective of this study was to develop an improved predictive model with reduced overfitting and improved accuracy in predicting RHF in LVAD recipients. The study involved 11,967 patients who underwent continuous-flow LVAD implantation between 2008 and 2016, with an RHF incidence of 9% at 1 year. Using an eXtreme Gradient Boosting (XGBoost) algorithm, the training data were used to predict RHF at 1 year postimplantation, resulting in promising area under the curve (AUC)-receiver operating characteristic (ROC) of 0.8 and AUC-precision recall curve (PRC) of 0.24. The calibration plot showed that the predicted risk closely corresponded with the actual observed risk. However, the model based on data collected 48 hours before LVAD implantation exhibited high sensitivity but low precision, making it an excellent screening tool but not a diagnostic tool.

Pre- and Post-Implant Endoscopy in Left Ventricular Assist Device Recipients: A Single-Center Experience.

Gastrointestinal bleeding (GIB) is common in left ventricular assist devices (LVADs) patients, but the optimal screening approach before LVAD implantation is still unclear. The aim of the study was to describe our experience with pre- and post-LVAD implantation endoscopic screening and subsequent GI bleeding in this cohort. A retrospective review was conducted among all patients who underwent LVAD implantation at Saint Luke's Hospital, between 2010 and 2020. The data were reviewed to determine the yield and safety of endoscopic procedures performed within 1 month before LVAD placement and the incidence of GIB within 1 year after implantation. A total of 167 LVAD patients met the inclusion criteria, and 23 underwent pre-implantation endoscopic evaluation. Angiodysplasia had a significantly higher odds ratio (OR) of 9.41 (95% confidence interval (CI): 2.01 - 44.09) in post-LVAD endoscopy, while there was no significant difference in bleeding from other sources such as peptic ulcer disease or diverticular bleeding. There was no difference in the incidence of GIB in patients who underwent endoscopic evaluation pre-LVAD compared to post-LVAD GIB (32.6% vs. 39.1%, P = 0.64). Endoscopy was well-tolerated in this cohort, and argon plasma coagulation was the most commonly used intervention to achieve hemostasis. According to our results, we recommend against routine pre-LVAD endoscopic screening. Instead, we suggest an individualized approach, where decisions are made on a case-by-case basis.

Differences in early outcomes for left ventricular assist device recipients implanted before and during the COVID-19 pandemic.

Differences in early outcomes for left ventricular assist device recipients implanted before and during the COVID-19 pandemic.

Is hemolysis a predictor of complications in patients implanted with a left ventricular assist device?

Aim: Life-threatening complications such as intra-device thrombus, infection, bleeding, kidney and liver failure are frequently encountered due to the use of left ventricular assist devices (LVADs). We aimed to determine the incidence of hemolysis in patients implanted with LVAD, the mechanical complications detected in patients with hemolysis, and whether hemolysis can be used as a predictor of complications. Material and Methods: In this single-center, retrospective clinical research study, we evaluated 40 patients with HeartWare (HeartWare International, Inc., MA, USA) LVAD implants to assess the incidence of hemolysis and its association with mechanical complications. Hemolysis parameters, including lactate dehydrogenase (LDH), bilirubin, serum-free hemoglobin (sfHg), corrected reticulocyte count (CRC), and haptoglobin, were measured in venous blood samples obtained from patients attending cardiovascular outpatient clinics. Patients were divided into two groups( group 1:without hemolysis,n=32; group 2: with hemolysis,n=8) based on the presence or absence of hemolysis, and demographic data, comorbidities, and laboratory results were compared. The time elapsed after implantation of the patients was min: 90 days, max: 3147 days. Results: Hemolysis was detected in 20% (8 out of 40) of the patients included in the study. Patients with hemolysis demonstrated higher CRC, LDH, and total bilirubin levels(p&lt;0,005), and lower haptoglobin levels compared to those without hemolysis(p&lt;0,001). Intra-device thrombus was detected as a mechanical complication in 2 patients with hemolysis. One patient died and the other was discharged after medical treatment. Conclusion: Our findings suggest that routine monitoring of hemolysis parameters in LVAD recipients may aid in the early detection of mechanical complications, such as pump thrombosis, before symptomatic manifestation, thus potentially reducing mortality. Assessing multiple parameters, including LDH, bilirubin, sfHg, CRC, and haptoglobin, is crucial for accurate hemolysis diagnosis and its association with mechanical complications. It should be supported by large series of studies with longer and similar follow-up periods and a larger number of patients.

Perioperative Management And Episode Of Care Outcomes Following Hip Or Knee Arthroplasty Among Left Ventricular Assist Device Recipients

Perioperative Management And Episode Of Care Outcomes Following Hip Or Knee Arthroplasty Among Left Ventricular Assist Device Recipients

Intravenous administration of umbilical cord lining stem cells in left ventricular assist device recipients: Results of the uSTOP LVAD BLEED pilot study

PurposeLeft ventricular assist device (LVAD) implantation improves survival in advanced heart failure. Despite this, angiodysplastic bleeding complications remain a significant driver of costs as well as morbidity. Mechanisms implicated in post LVAD implant bleeding include the dysregulation of angiogenic factors seen in this population. The present pilot study evaluates the safety of umbilical cord lining stem cells (ULSCs) in LVAD recipients while exploring any early evidence of efficacy to improve bleeding. MethodsIn a 3 + 3 design, 9 patients received an intravenous (IV) infusion of ULSCs at escalating doses. The primary endpoint was safety and tolerability, secondary exploratory outcomes included antibodies against hemoglobin to quantify the amount of blood in stool without need for dietary restriction. ResultsThe primary safety and tolerability outcomes were met as no infusion related adverse events or toxic responses were observed. There was no sensitization after administration of ULSCs as assessed by panel reactive antibody. An increase in Angiopoetin-1 levels and a decrease in Angiopoetin-2 levels from baseline to 30 days were observed in 4 patients. Quantitative Faecal Immunochemical Test suggested a decrease in the mean blood content of stool from baseline to 30 days. ConclusionsIn this first ever IV administration of ULSCs in LVAD patients, infusion was noted to be safe and tolerable and did not cause immune sensitization. Half of the patients were noted to have angiogenic stabilization, and there was a trend towards decreasing amounts of blood noted in the stool, suggesting an early signal of efficacy.

Gastrointestinal bleeding following Heartmate 3 left ventricular assist device implantation: The Michigan Bleeding Risk Model

BackgroundGastrointestinal bleeding (GIB) results in frequent hospitalizations and impairs quality of life in durable left ventricular assist device (LVAD) recipients. Anticipation of these events before implantation could have important implications for patient selection and management. MethodsThe study population included all adult HeartMate 3 (HM3) primary LVAD recipients enrolled in the STS-Intermacs registry from January 2017-December 2020. Using multivariable modeling methodologies, we investigated the relationships between preimplantation characteristics and postimplant bleeding, bleeding and death, and additional bleeding episodes on subsequent bleeding episodes, and created a risk score to predict the likelihood of post-LVAD GIB based solely on pre-implantation factors. ResultsOf 6425 patients who received a HM3 LVAD, 1010 (15.7%) patients experienced GIB. Thirteen pre-implantation factors were independent predictors of post-LVAD GIB. A risk score was created from these factors and calculated for each patient. By 3-years postimplant, GIB occurred in 11%, 26%,and 43% of low-, medium- and high-risk patients. Experiencing one post-LVAD GIB event was associated with an increased risk for further GIB events, with 33.9% of patients experiencing at least one recurrence. While post-LVAD GIB was associated with mortality, there was no relationship between number of GIB events and death. ConclusionThe Michigan Bleeding Risk Model is a simple tool which facilitates the prediction of post-LVAD GIB in HM3 recipients, by using 13 pre-implant variables. The implementation of this tool may help in the risk stratification process and may have therapeutic and clinical implications in HM3 LVAD recipients.

Non-Medical Characteristics Affect Referral for Advanced Heart Failure Services: a Retrospective Review.

Patients with advanced heart failure (AHF) are extensively evaluated before heart transplantation or left ventricular assist device (LVAD) eligibility. Patients are assessed for medical need and psychosocial or economic factors that may affect success post-treatment. For patients to be evaluated, however, they first must be referred. This study investigated social and economic factors affecting AHF referral, specialist visits, or treatment. Patients with heart failure (n = 24,258) were reviewed at one large hospital system over 4years. Independent variables age, sex, marital status, race/ethnicity, preferred language, smoking, and insurance status were assessed for the outcomes of referral, clinic visit, and treatment by Chi-square and ANOVA. In-house and 1-year mortality were evaluated by logistic regression, and time-to-event was assessed by the Cox proportional hazards model. Younger (HR 0.934, 95% CI 0.925-0.943), male (HR 2.216, 95% CI 1.544-3.181), and publicly insured (HR 1.298 [95% CI 1.038, 1.623]) patients were more likely to be referred, while unmarried (HR 0.665, 95% CI 0.488-0.905) and smoking (HR 0.549, 95% CI 0.389-0.776) patients had fewer referrals. Younger, married, and nonsmoking patients were more likely to have a clinic visit. Younger age, White race, and Hispanic/Latino ethnicity were associated with receiving a heart transplant, and LVAD recipients were more likely Hispanic/Latino ethnicity. Advanced age, Hispanic/Latino ethnicity, and smoking were associated with 1-year mortality after heart failure diagnosis. Disparities in access exist before evaluation for AHF therapies. Improving access at the levels of referral and evaluation is a necessary step toward achieving equity in organ allocation.

Associations Between Preimplant Cancer Type and Left Ventricular Assist Device Outcomes: An INTERMACS Registry Analysis.

We used the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database to examine whether history of a solid versus hematologic malignancy impacts outcomes after left ventricular assist device (LVAD) implantation. We included LVAD recipients (2007-2017) with cancer history reported (N = 14,799, 21% female, 24% Black). Multivariate models examined the association between cancer type and post-LVAD mortality and adverse events. Competing risk analyses compared death and heart transplantation between cancer types and those without cancer in bridge-to-transplant (BTT) patients. A total of 909 (6.1%) patients had a history of cancer (4.9% solid tumor, 1.3% hematologic malignancy). Solid tumors were associated with higher mortality (adjusted hazard ratio [aHR] = 1.31, 95% confidence interval [CI] = 1.09-1.57), major bleeding (aHR = 1.15, 95% CI = 1.00-1.32), and pump thrombosis (aHR = 1.52, 95% CI = 1.09-2.13), whereas hematologic malignancies were associated with increased major infection (aHR = 1.43, 95% CI = 1.14-1.80). Compared to BTT patients without a history of cancer, solid tumor patients were less likely to undergo transplantation (adjusted subdistribution HR [aSHR] = 0.63, 95% CI = 0.45-0.89) and hematologic malignancy patients were as likely to experience death (aSHR = 1.16, 95% CI = 0.63-2.14) and transplantation (aSHR = 0.69, 95% CI = 0.44-1.08). Cancer history and type impact post-LVAD outcomes. As LVAD utilization in cancer survivors increases, we need strategies to improve post-LVAD outcomes in these patients.

Occult right ventricular dysfunction and right ventricular-vascular uncoupling in left ventricular assist device recipients

BackgroundCurrent assessments remain insensitive for detecting right heart failure post left ventricular assist device (LVAD). Sensitive pressure-volume loop assessments of right ventricle (RV) contractility may improve our appreciation of post-LVAD RV dysfunction. MethodsThirteen LVAD patients and 20 reference (non-LVAD) subjects underwent comparison of echocardiographic, right heart cath hemodynamic, and pressure-volume loop-derived assessments of RV contractility using end-systolic elastance (Ees), RV afterload by effective arterial elastance (Ea), and RV-pulmonary arterial (RV-PA) coupling (ratio of Ees/Ea). ResultsLVAD patients had lower RV Ees (0.20±0.08 vs. 0.30±0.15 mmHg/ml, p=0.01) and lower RV Ees/Ea (0.37±0.14 vs 1.20±0.54, p<0.001) versus reference subjects. Low RV Ees correlated with reduced RV septal strain, an indicator of septal contractility, in both the entire cohort (r=0.68, p=0.004) as well as the LVAD cohort itself (r=0.78, p=0.02). LVAD recipients with low RV Ees/Ea (below the median value) demonstrated more clinical heart failure (71% vs 17%, p=0.048), driven by an inability to augment RV Ees (0.22±0.11 vs 0.19±0.02 mmHg/ml, p=0.95) to accommodate higher RV Ea (0.82±0.38 vs 0.39±0.08 mmHg/ml, p=0.002). Pulmonary artery pulsatility index (PAPi) best identified low baseline RV Ees/Ea (≤0.35) in LVAD patients (AUC=0.80); during ramp study, change in PAPi also correlated with change in RV Ees/Ea (r=0.58, p=0.04). ConclusionsLVAD patients demonstrate occult intrinsic RV dysfunction. In the setting of excess RV afterload, LVAD patients lack the RV contractile reserve to maintain ventriculo-vascular coupling. Depression in RV contractility may be related to LVAD LV unloading which reduces septal contractility.

Catheter Ablation for Tachyarrhythmias in Left Ventricular Assist Device Recipients: Clinical Significance and Technical Tips.

The demand for durable left ventricular assist devices (LVADs) has been increasing worldwide in tandem with the rising population of advanced heart failure patients. Especially in cases of destination therapy, instead of bridges to transplantation, LVADs require a lifelong commitment. With the increase in follow-up periods after implantation and given the lack of donor hearts, the need for managing concomitant tachyarrhythmias has arisen. Atrial and ventricular arrhythmias are documented in approximately 20% to 50% of LVAD recipients during long-term device support, according to previous registries. Atrial arrhythmias, primarily atrial fibrillation, generally exhibit good hemodynamic tolerance; therefore, catheter ablation cannot be easily recommended due to the risk of a residual iatrogenic atrial septal defect that may lead to a right-to-left shunt under durable LVAD supports. The clinical impacts of ventricular arrhythmias, mainly ventricular tachycardia, may vary depending on the time periods following the index implantation. Early occurrence after the operation affects the hospitalization period and mortality; however, the late onset of ventricular tachycardia causes varying prognostic impacts on a case-by-case basis. In cases of hemodynamic instability, catheter ablation utilizing a trans-septal approach is necessary to stabilize hemodynamics. Nonetheless, in some cases originating from the intramural region or the epicardium, procedural failure may occur with the endocardial ablation. Specialized complications associated with the state of LVAD support should be carefully considered when conducting procedures. In LVAD patients, electrophysiologists, circulatory support specialists, and surgeons should collaborate as an integrated team to address the multifaceted issues related to arrhythmia management.

Abstract 18112: LVAD Recipient and Caregiver Perspective on Prognosis and End of Life Care: A Qualitative Study

Background: For left ventricular assist device (LVAD) recipients and caregivers, accurate understanding of prognosis is central to shared decision making. Our study evaluates (i) patient and caregiver estimated survival after a LVAD and (ii) describes how patients and caregivers rationalize estimated survival. Methods: We conducted a qualitative study with 18 LVAD recipients and 9 caregivers using semi-structured interviews. Interviews were transcribed and coded, with themes identified using rapid qualitative analysis. Results: Included patients had a median (range) age of 60.5 (28-83) years, 12 (67%) were men and 10 (56%) received their LVAD as destination therapy (DT). Participating caregivers included 8 (89%) women supporting 5 (56%) DT LVAD recipients. Depression was reported by 7 (39%) patients and 2 (22%) caregivers. Reported quality of life was low for most participants [median EQ-VAS score 60 (range 25-70) for patients and 50 (range 20-80) for caregivers]. Only 6 patients reported willingness to trade survival in favor of better quality of life. In the event of cardiac arrest, 15 (83%) patients and 7 (78%) caregivers reported wanting CPR for themselves or loved one. Although most participants reported health concerns primarily relating to their cardiac health and LVAD complications, both patients and caregivers provided high estimates of life expectancy [median 16 (range 3-45) and 14 (range 3-32) years respectively]. We identified three themes explaining how LVAD recipients and caregivers rationalize their estimated survival (i) survivor’s bias (ii) optimism (iii) minimization. Exemplary quotes are provided in the Table below. Conclusions: Several patients and caregivers reported low quality of life with concerns around poor cardiovascular health and LVAD complications. However, their estimated survival frequently exceeded clinically observed survival. This suggests an opportunity for improving patient-physician prognosis communication.