Left Ventricular Assist Devices Population Research Articles

Electroconvulsive Therapy in a Left Ventricular Assist Device Recipient With Treatment-Resistant Depression.

Depression and heart failure are highly comorbid, with up to 35% of heart failure patients suffering from comorbid depression. Left ventricular assist devices (LVADs) serve as a major lifeline for patients with heart failure; however, despite the drastic improvement in cardiac function following LVAD implantation, up to 24% of LVAD recipients suffer from depression. Depression management in LVAD recipients is often complicated by the recipient's increased risk for antidepressant side effects, adverse drug reactions, and inability to safely receive certain interventional psychiatry therapies, as the LVAD is either a relative or absolute contraindication. Electroconvulsive therapy (ECT) is highly effective for treatment-resistant depression; although it carries increased cardiovascular risks for the LVAD population (particularly bradycardia/hypotension and tachycardia/hypotension), these can be continuously monitored, along with LVAD function, such that with the close cooperation of a multidisciplinary team, the risks of ECT can be minimized. To our knowledge, there is only one published case report of ECT in an LVAD recipient. We present a case of an LVAD recipient with treatment-resistant depression who was successfully treated with ECT. Our case describes an approach by which ECT can be safely delivered to LVAD recipients with a collaborative multidisciplinary team approach.

Changes in right ventricular two-dimensional echocardiographic speckle-tracking indices in adult LVAD population: a prospective clinical study

Abstract Objective Preserved right ventricular (RV) function is crucial in patients supported with left ventricular assist devices (LVAD). The use of strain derived from speckle tracking echocardiography (STE) is recommended by recent guidelines to evaluate intricate RV contractility. The data regarding long-term RV observation in LVAD patients using STE are limited. Thus, the study aimed to determine RV systolic function by STE in the remote period after LVAD implantation. Methods Patients with implanted third-generation LVADs with hydrodynamic bearing were prospectively enrolled (NCT05063006). The RV STE indices were analyzed before and after LVAD implantation, both at rest and during the cycle ergometer exercise test. Results We included 22 patients, the mean age was 58.4±7 years, 95.5% were men, and 45.5% had dilated cardiomyopathy. Stress tests were conducted 7 months postoperatively. The RV strain analysis was feasible in all subjects both in rest and exercise. The RV free wall strain (RVFWS) worsened from −13% (IQR, −17.3 to −10.9) to −11.3% (IQR, −12.9 to −6; p=0.033) after LVAD implantation with the particular decline in the apical RV segment [−11.3% (IQR, −16.4 to −6.2) vs −7.8% (IQR, −11.7 to −3.9; p=0.012)]. The RV four-chamber longitudinal strain (RV4CSL) remained unchanged [−8.5% (IQR, −10.8 to −6.9) vs −7.3% (IQR, −9.8 to −4.7; p=0.184)]. Neither RVFWS (−11.3% (IQR, −12.9 to −6) vs −9.9% (IQR, −13.5 to −7.5; p=0.077) nor RV4CSL [−7.3% (IQR, −9.8 to −4.7) vs −7.9% (IQR, −9.8 to −6.3; p=0.548)] changed during cycle ergometer stress test. Conclusion The RVFWS worsens after LVAD implantation presumably due to impaired apical contractility. In LVAD-supported patients during the cycle ergometer stress test, the detailed RV strain analysis is feasible and its indices remain unchanged. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): 1. Cor Aegrum Foundation of Cardiac Surgery Development in Cracow2. Medtronic Poland sp. z o.o.

Mechanical thrombectomy after acute ischemic stroke in patients with left ventricular assist devices: A nationwide analysis.

Left ventricular assist devices (LVADs) are an established, durable, and life-saving treatment option for patients with advanced heart failure. However, large vessel occlusions (LVOs) remain one of its most devastating embolic complications. Mechanical thrombectomy (MT) is safe and effective in the management of LVOs in the general population, but LVO trials largely excluded patients on mechanical circulatory support, and large-scale analyses of outcomes following these interventions in the LVAD population are lacking. Using the National Inpatient Sample, we identified all adult patients hospitalized with acute ischemic stroke (AIS) from 2005 to 2018. Regression models adjusting for patient demographics, hospital factors, and clinical severity were used to compare outcomes following MT in patients with and without LVAD. Subgroup analyses were also performed in LVAD patients experiencing stroke in the post-operative setting and stroke in the setting of pre-existing devices. Of the 1,633,234 AIS hospitalizations identified, 794 occurred in patients with LVADs. Around 61% were post-operative. Post-stroke in-hospital mortality was higher among patients with LVADs (23.3% vs 7.23%, P < 0.001). Among those receiving MT, mortality was also higher in the LVAD population (31.0% vs 14.1%, P = 0.009), though this was largely driven by the post-operative LVAD subgroup. In multivariable analysis, only post-operative LVAD patients experienced greater odds of in-hospital death after MT (adjusted odds ratio (aOR): 8.66, confidence interval (CI):1.46-51.3); patients with pre-existing LVADs demonstrated no difference in post-MT mortality (aOR: 1.06; 95% CI: 0.29-3.91) or in odds of discharge home after MT (aOR 0.63, CI: 0.17-2.32). Our data suggest MT is not a futile treatment approach in patients with pre-existing LVADs and may result in similar rates of good outcomes. Additional research is needed to evaluate the long-term benefits of endovascular therapy after stroke in patients on LVAD support.

Does Hemoglobin A1c Accurately Depict Diabetic Control in LVAD Patients?

PurposeDiabetes is common in patients implanted with left ventricular assist devices (LVAD). Poor diabetic control increases infection risk, inflammatory markers, and thrombotic risk. Typical hemoglobin A1c (HbA1c) calculations rely on a normal red blood cell life span, which may result in an artificially low HbA1c. Fructosamine is a glycated protein product able to be extrapolated to estimated average glucose as HbA1c. The validity of these two values in the LVAD population is unknown.MethodsA retrospective review on LVAD patients implanted from 2010 to 2021 was completed on patients with simultaneous fructosamine, LDH, and HbA1c levels. Patient characteristics, demographics, and diabetic history were collected and analyzed.ResultsNine patients were implanted with HeartMate 2 (67%), HeartMate 3 (11%), and HeartWare (22%) devices. Most were male (67%), destination therapy (89%), with dilated cardiomyopathy (56%) etiology. HbA1c underestimated fructosamine-derived HbA1c values at higher fructosamine levels (p=0.0008) suggesting that HbA1c may underestimate average glucose (Figure 1). Levels of LDH appeared unrelated to the HbA1c or fructosamine values. .ConclusionThese data demonstrate variability between calculated HbA1c derived from fructosamine and HbA1c blood levels in LVAD patients. At higher fructosamine levels, A1c may underestimate average glucose levels and falsely reassure about adequate glucose control. Alternative methodologies for assessing diabetic control, such as fructosamine, may be warranted, but further data should correlate average glucose values to these cumulative indices. Diabetes is common in patients implanted with left ventricular assist devices (LVAD). Poor diabetic control increases infection risk, inflammatory markers, and thrombotic risk. Typical hemoglobin A1c (HbA1c) calculations rely on a normal red blood cell life span, which may result in an artificially low HbA1c. Fructosamine is a glycated protein product able to be extrapolated to estimated average glucose as HbA1c. The validity of these two values in the LVAD population is unknown. A retrospective review on LVAD patients implanted from 2010 to 2021 was completed on patients with simultaneous fructosamine, LDH, and HbA1c levels. Patient characteristics, demographics, and diabetic history were collected and analyzed. Nine patients were implanted with HeartMate 2 (67%), HeartMate 3 (11%), and HeartWare (22%) devices. Most were male (67%), destination therapy (89%), with dilated cardiomyopathy (56%) etiology. HbA1c underestimated fructosamine-derived HbA1c values at higher fructosamine levels (p=0.0008) suggesting that HbA1c may underestimate average glucose (Figure 1). Levels of LDH appeared unrelated to the HbA1c or fructosamine values. . These data demonstrate variability between calculated HbA1c derived from fructosamine and HbA1c blood levels in LVAD patients. At higher fructosamine levels, A1c may underestimate average glucose levels and falsely reassure about adequate glucose control. Alternative methodologies for assessing diabetic control, such as fructosamine, may be warranted, but further data should correlate average glucose values to these cumulative indices.

Early To Bed, Early To Rise: LVAD Patients And Sleep Patterns

Early To Bed, Early To Rise: LVAD Patients And Sleep Patterns

“Stable” Asystole In A Patient With Left Ventricular Assist Device

The use of Left Ventricular assist devices (LVADs) for mechanical circulatory support has become a standard therapy for some patients with end-stage heart failure. Although presentation and consequences of ventricular arrhythmias (VA) in LVAD supported patients are well described and often stabilized by the mechanical support, presence of asystole is less commonly reported. Our patient is a 75-year-old male with advanced ischemic cardiomyopathy requiring cardiac resynchronization therapy-defibrillator (CRT-D) and ultimately HeartMate II LVAD. Post implantation, his CRT-D was abandoned after it reached the elective replacement indicator as he had no VAs and was not pacer dependent. He now presented with a new onset of low flow alarms that started earlier in the day. He appeared stable, pleasant and in a humorous mood. He reported lightheadedness but denied syncope. While in the ED, the patient was noted to be asystolic. His mean arterial pressure was in the 50s. Physical exam was unremarkable with the expected LVAD hum and lack of pulses. LVAD parameters revealed decreased Flow (2.5 from baseline 5.1) and Pulsatility Index (2.7 from baseline 4.9). Patient subsequently underwent implantation of a new battery with reactivation of his previously abandoned pacemaker leads with resultant hemodynamic improvement. Ultimately, he was discharged home in stable condition. Discussion: Very few cases of asystolic LVAD patients without immediate hemodynamic collapse are described. Similarly to ventricular arrhythmias, the hypothesized physiology for stability is this quasi-Fontan circulation, where low pulmonary vascular resistance with elevated central venous pressure allows pulmonary vasculature perfusion and left atrial filling. In this case, low flow alarms and decreased PI were due to decreased left ventricular preload in the setting of asystole. Ventricular arrhythmias remain common after LVAD implantation, asystole, as in the present case can equally be an issue. This is particularly true as many of LVAD supported patients have CRT-Ds implanted in the setting of pre-existent left bundle branch blocks, which can progress to complete heart block or asystole. Thus, It might not always be the case that LVAD supported patients don't benefit from maintaining ICD function. Conclusion: Traditionally unstable asystole and ventricular arrhythmia can be well tolerated in the LVAD population due to quasi-Fontan physiology. ICD role in LVAD patients is currently unclear, and should be a part of shared decision making with the patient. Yes, there may be such a thing as, "stable" asystole.

A Comparison of the LVAD Population 1-Year Clinical Outcomes Before and After the Transplant Allocation System Change

<h3>Purpose</h3> In October 2018, the transplant allocation system deprioritized left ventricular assist devices (LVAD) as an indication for heart transplant. After the allocation system change, the majority of LVADs are implanted as destination therapy. As a greater proportion of LVAD patients are implanted as destination therapy, we hypothesized that the overall population of patients implanted after the allocation system change will experience less favorable 12-month outcomes and decreased rates of progression to transplant as compared to those implanted prior. <h3>Methods</h3> The data cohort includes patients implanted with LVADs at an academic high volume transplant center since 2005. The overall cohort was divided into two groups- those implanted prior to the allocation system change and those implanted after. Baseline characteristics and one-year outcomes were compared; survival curves were constructed using the Kaplan-Meier method and compared using the log-rank test. <h3>Results</h3> 50 patients were implanted with a LVAD between November 1^st, 2018 and July 1^st, 2020, and 181 patients received an implant between 2005 and before November 1^st, 2018. After the allocation system change, 86% of patients received a LVAD as destination therapy, compared to 45.4% implanted prior to allocation system change (p<0.0001). Patients who were implanted prior to the allocation system change had a lower pre-implant INTERMACS status than those implanted after the change (p=0.0001), and had a higher rate of device malfunction and pump thrombosis (p=0.02). The log-rank test comparing the survival curves for the combined outcome of death and rehospitalization did not demonstrate a significant difference (p=0.63). We did not find a significant difference in time from implant to transplantation nor in the rate of transplantation. <h3>Conclusion</h3> While there were important differences in baseline characteristics and outcomes, patients implanted with a LVAD after the allocation system change did not clearly have poorer pre-implant health, 1 year outcomes, or lower rates of transplantation at 1 year than patients implanted after. Furthermore, the practice patterns of transplanting patients with a LVAD did not change significantly at this academic high volume transplant center.

Abstract TMP64: Outcomes After Mechanical Thrombectomy In Patients With Left Ventricular Assist Devices

Background: Left ventricular assist devices (LVADs) are an established durable and lifesaving treatment option for patients with advanced heart failure. However, large vessel occlusions (LVOs) remain one of its most devastating embolic complications. Mechanical thrombectomy (MT) is safe and effective in the management of LVOs in the general population but LVO trials largely excluded patients on mechanical circulatory support and large-scale analyses of outcomes following these interventions in the LVAD population are lacking. Methods: Using the National Inpatient Sample (2012 - 2018) we identified all adult patients hospitalized with acute ischemic stroke (AIS). The presence of LVAD, the use of MT, and additional covariates were extracted. Descriptive statistics and multivariable regression models were used to compare outcomes following MT in patients with and without LVADs. Results: Of the 798,059 AIS hospitalizations identified, 366 occurred in patients with LVADs. LVAD patients were younger (mean age 59.6 [13.2] vs 70.1 [14.3], p &lt;0.001), and were less often female (23.0% vs 50.9%, p &lt;0.001). In the general stroke population 2% were treated with MT vs 6% in LVAD-associated AIS. Post-stroke mortality was higher among LVAD patients (18.4% vs 6.22, p=0.000). However, among patients receiving MT, there was no significant difference in in-hospital mortality between LVAD and non-LVAD patients (23.1% vs 12.5%, p=0.104). In crude analysis and after adjusting for potential confounders there was no difference in odds of discharge to home after treatment with MT (Figure). Conclusion: Our data suggests MT is not a futile treatment approach in patients with LVADs and may result in similar rates of good outcomes. Additional research is needed to evaluate the long-term benefits of endovascular therapy after stroke in patients on LVAD support.

Association between early ventricular arrhythmias and mortality in destination vs. bridge patients on continuous flow LVAD support

The association between ventricular arrhythmias (VAs) and mortality in patients supported by continuous flow left ventricular assist devices (LVAD) remains controversial. To evaluate the association between pre-implantation, early (≤ 30 day) post-implantation VAs and mortality in bridge to transplant (BTT) and destination therapy (DT) LVAD patients, separately. The risk factors for post LVAD VAs were also investigated. In this observational cohort study, we included 341 patients who received a first time, continuous flow LVAD between January 1st 2010 and July 30th 2018. We used Kaplan–Meier curves and multivariable cox regression analyses to study the association between VAs and mortality in the BTT and DT populations. The mean age of the cohort was 58 ± 14 years, with 82% males, 53% had ischemic cardiomyopathy, and 45% were DT. The mean follow-up was 2.2 ± 2.1 years. In both BTT and DT cohorts, pre LVAD VAs were not associated with mortality after LVAD implantation (log-rank p = 0.95 and p = 0.089, respectively). In the BTT population, early post-LVAD VAs were not statistically associated with increased mortality (log rank p = 0.072). In the DT patients, early post LVAD VAs were associated with a 67% increase in the hazards rate of mortality on LVAD support (HR 1.67 [1.05–2.65], p = 0.029). The final model was adjusted for type of cardiomyopathy, INTERMACS profile, glomerular filtration rate, post LVAD atrial fibrillation, age and cerebrovascular events. Early post-LVAD VA is common after LVAD implantation and is an independent predictor of mortality in the DT LVAD population.

Does endoscopic intervention prevent subsequent gastrointestinal bleeding in patients with left ventricular assist devices? A retrospective study.

BACKGROUNDPatients with left ventricular assist devices (LVADs) are at increased risk for recurrent gastrointestinal bleeding (GIB) and repeat endoscopic procedures. We assessed the frequency of endoscopy for GIB in patients with LVADs and the impact of endoscopic intervention on preventing a subsequent GIB.AIMTo evaluate for an association between endoscopic intervention and subsequent GIB. Secondary aims were to assess the frequency of GIB in our cohort, describe GIB presentations and sources identified, and determine risk factors for recurrent GIB.METHODSWe conducted a retrospective cohort study of all patients at a large academic institution who underwent LVAD implantation from January 2011 – December 2018 and assessed all hospital encounters for GIB through December 2019. We performed a descriptive analysis of the GIB burden and the outcome of endoscopic procedures performed. We performed multivariate logistic regression to evaluate the association between endoscopic intervention and subsequent GIB.RESULTSIn the cohort of 295 patients, 97 (32.9%) had at least one GIB hospital encounter. There were 238 hospital encounters, with 55.4% (132/238) within the first year of LVAD implantation. GIB resolved on its own by discharge in 69.8% (164/235) encounters. Recurrent GIB occurred in 55.5% (54/97) of patients, accounting for 59.2% (141/238) of all encounters. Of the 85.7% (204/238) of encounters that included at least one endoscopic evaluation, an endoscopic intervention was performed in 34.8% (71/204). The adjusted odds ratio for subsequent GIB if an endoscopic intervention was performed during a GIB encounter was not significant (odds ratio 1.18, P = 0.58).CONCLUSIONPatients implanted with LVADs whom experience recurrent GIB frequently undergo repeat admissions and endoscopic procedures. In this retrospective cohort study, adherence to endoscopic guidelines for performing endoscopic interventions did not significantly decrease the odds of subsequent GIB, thus suggesting the uniqueness of the LVAD population. A prospective study is needed to identify patients with LVAD at risk of recurrent GIB and determine more effective management strategies.

Sustained Ventricular Fibrillation in a Conscious Pediatric LVAD Patient

<h3>Introduction</h3> Non-sustained ventricular tachycardia (NSVT), defined by ventricular tachycardia lasting less than 30 seconds, is common in patients with left ventricular assist devices (LVADs)​. Ventricular tachy-arrhythmias (VAs) such as sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) are uncommon but carry a significant risk of morbidity and death. <h3>Case Report</h3> A 16-year-old male underwent continuous flow LVAD implantation after presenting with end stage heart failure due to dilated cardiomyopathy. Prior to LVAD, he had an increasing burden of NSVT, which improved post-LVAD insertion. On post-op day 11, he developed palpitations related to sinus tachycardia and monomorphic NSVT. He remained conscious with clinical signs of adequate peripheral perfusion. The VAD flows fell from 5.2 L/min to 1.9 L/min secondary to the effects of the VA on the right ventricle (RV). The VAs then deteriorated into sustained polymorphic VT followed by VF (<i>Image 1</i>). He continued to answer questions appropriately but complained of dizziness and visual changes. Medical management included lidocaine, calcium, magnesium, amiodarone, and epinephrine for RV support. In addition, he received 4 defibrillations, the last of which successfully converted him to sinus rhythm. He did not require chest compressions and maintained adequate cardiac output throughout. He underwent cardiac catheterization which confirmed normal coronary arteries and enabled optimization of LVAD settings. He was discharged home 15 days later on LVAD support, with amiodarone, metoprolol and a home automated external defibrillator. He remains well 10 months later with no further events. <h3>Summary</h3> VF, a potentially life-threatening arrhythmia, was remarkably well tolerated in a teenager on LVAD support despite some evidence of RV compromise. This case highlights the importance of improved risk stratification of NSVTs in the LVAD population to establish the need for anti-arrhythmic medication or implantable cardioverter-defibrillator.

Bridge to Transplant Outcomes with Axillary Intra-Aortic Balloon Pump versus Durable Left Ventricular Assist Device in the Current UNOS Heart Allocation System

Purpose Since the 2018 UNOS Allocation system for heart transplantation change there has been concern for increased wait times for patients with durable left ventricular assist devices (LVAD) as bridge to transplantation (BTT). Furthermore, there are increasing trends to utilize axillary intra-aortic balloon pumps (Ax-IABP) to optimize cardiac unloading while maintaining ambulatory status in listed hospitalized patients. BTT outcomes data for Ax-IABP patients is limited. Understanding risks vs benefits of prolonged support with Ax-IABP vs LVAD in the current UNOS allocation environment is imperative. Methods We performed a single center retrospective review from October 18, 2017 to October 18, 2019 for all patients who underwent heart transplant. Waitlist times based on device (Ax-IABP or LVAD) to transplant were assessed in addition to time from transplant to discharge. Intraoperative cardiopulmonary bypass time, transfusion requirements and post-operative vasoactive support was also compared. Results 59 heart transplants occurred during our review period. 8 bridged with Ax-IABP (13%) and 22 with LVAD (37%). Average age in both groups was 53 with 75% and 68% males in the IABP and LVAD groups respectively. More LVAD as BTT were transplanted prior to the UNOS change (13 vs. 9). All Ax-IABP patients were transplanted after the UNOS change. Waitlist time for LVAD was higher than Ax-IABP patients (109d vs. 575d, p=0.0003). Waitlist time before and after UNOS change was not statistically different among LVAD patients, but did increase (497d vs 688d, p=0.176). Cardiopulmonary bypass time was longer in LVAD patients, but not significant, despite similar UNOS Status at transplant. More PRBC transfusions in the LVAD group (7.5u, IQR 0u - 24u) compared to the Ax-IABP group (2.6u, IQR 0u - 6u, p=0.0012). Time from transplant to discharge was 25 days for LVAD group and 13 for Ax-IABP group (p=0.075). Conclusion Waitlist time and transfusion requirements are statistically increased in LVAD as compared to Ax-IABP as BTT. In the current listing schema for heart transplant, risk vs. benefit of increased waiting time, perioperative hemodynamic compromise and increased transfusions in the LVAD population pose significant concerns. Further prospective studies with larger cohorts may be needed to better evaluate this trend.

Guideline-Directed Heart Failure Therapy in Patients after Left Ventricular Assist Device Implantation

Background: Left ventricular assist devices (LVADs) are used as an advanced therapy option for patients with stage D heart failure. These devices provide mechanical unloading of the heart as either a bridge to transplant or recovery, or as destination therapy. In patients with LVADs, there are emerging data on the use of heart failure guideline-directed medical therapy (GDMT) to improve outcomes. This review describes the current evidence available for the use of neurohormonal blocking agents in patients with LVADs. Methods: Articles were found using PubMed and web searches for heart failure therapies/neurohormonal blockade and LVADs. Studies were included if they evaluated the use of the heart failure therapies, either retrospectively or prospectively. Results: A total of 17 articles and 9 abstracts were reviewed. The totality of data surrounding the use of GDMT neurohormonal blockade in patients with LVADs are limited in nature. Much of the data are limited either by use of surrogate outcomes, single center evaluations, and/or small sample sizes. However, the evidence does support clinical benefit with associated mechanistic plausibility. More research is needed to understand appropriate patient selection and means to optimize these therapies in the LVAD population. Conclusion: Combined neurohormonal blockade appears to reduce morbidity and mortality in patients with LVAD implants.

Phosphodiesterase-5 Inhibitors and Outcomes During Left Ventricular Assist Device Support: A Systematic Review and Meta-Analysis

BackgroundPhosphodiesterase-5 inhibitors (PDE5i) have been used to treat pulmonary hypertension and right ventricular failure in patients with left ventricular assist devices (LVAD). The effects of PDE5i on post-LVAD outcomes including hemocompatibility-related adverse events are not well-established. This systematic review and meta-analysis aims to evaluate the effects of PDE5i on post-LVAD outcomes. Methods and ResultsA comprehensive literature search was conducted using Pubmed and Embase databases from inception through November 25, 2020, to compare post-LVAD outcomes in patients with or without PDE5i use. Pooled odds ratio (OR) with 95% confidence intervals (CI) and I2 statistic were calculated. Thirteen observational studies were included in this analysis. The use of PDE5i was not significantly associated with lower postoperative right ventricular failure (OR 0.38, 95% CI 0.02–5.96, P = .41). There was no significant association between PDE5i and gastrointestinal bleeding (OR 1.23, 95% CI 0.76–1.98, P = .2), overall stroke (OR 0.60, 95% CI 0.21–1.68, P = .17), ischemic stroke (OR 0.61, 95% CI 0.09–4.07, P = .38), or pump thrombosis (OR 0.71, 95% CI 0.14–3.54, P = .46). ConclusionsOur meta-analysis showed no significant association between PDE5i and post-LVAD right ventricular failure. Despite the antiplatelet effects of PDE5i, there was no significant association between PDE5i and gastrointestinal bleeding, overall stroke, ischemic stroke, or pump thrombosis. Randomized controlled studies are warranted to evaluate the net benefits or harms of PDE5i in the LVAD population.

Atrial arrhythmias in patients with left ventricular assist devices.

Atrial arrhythmias commonly occur in patients with advanced heart failure with reduced ejection fraction (HFrEF) who require left ventricular assist devices (LVADs) implantation. This review summarizes the current literature regarding the incidence, prevalence, and predictors of atrial arrhythmias in LVAD patients and its impact on the clinical outcomes. Moreover, we review the mechanisms and management strategies of atrial arrhythmias in this population. Atrial arrhythmias including atrial fibrillation, atrial flutter, and atrial tachycardia are highly prevalent in patients with advanced HFrEF before or after the LVAD implantation. Atrial arrhythmias have a significant impact on overall clinical outcome including survival, heart failure hospitalization, quality of life, thromboembolic events and resource utilization. Atrial fibrillation and other atrial arrhythmias frequently coexist in this population. In patients with atrial arrhythmias and LVAD, anticoagulation and cardiovascular implantable electronic devices should be closely monitored and managed to prevent thromboembolic events or inappropriate shocks. Rhythm and rate control strategies are comparable regarding overall clinical outcomes in this population. LVADs induce favorable atrial remodeling in patients with HFrEF. Atrial arrhythmias are highly common in LVAD patients and have significant impact on overall clinical outcomes. Further studies are needed to determine optimal management and prevention of atrial arrhythmias in LVAD population.

Intravenous Versus Oral Iron Replacement in Patients with a Continuous-Flow Left Ventricular Assist Device.

Intravenous Versus Oral Iron Replacement in Patients with a Continuous-Flow Left Ventricular Assist Device.

Obesity Is Associated with Driveline Infection of Left Ventricular Assist Devices.

In patients with left ventricular assist devices (LVADs), the association of driveline infection (DLI) and body mass index (BMI) remains controversial. The aim of this study was to explore a potential correlation between BMI and DLI in the LVAD patient population. A retrospective, single-center study evaluated patients who underwent LVAD implantation between May 2012 and July 2016. Driveline infection was evaluated per Interagency Registry for Mechanically Assisted Circulatory Support established criteria. Of 222 included patients, 80% were male, the average age was 55 years, and the main underlying heart failure diagnosis was nonischemic cardiomyopathy (56%). The majority of patients (65%) received LVAD as destination therapy and 35% as a bridge to transplantation. Average time-to-first DLI was 296 days after LVAD implantation. In comparison to non-DLI group (80%, N = 177), patients in DLI group (20%, N = 45) had a higher BMI (33.5 ± 8.3 kg/m in DLI group vs. 28.8 ± 7.5 kg/m in non-DLI group, p = 0.0003) and were younger (51 ± 12 years in DLI group vs. 56 ± 12 years in non-DLI group, p = 0.013). There was a significant correlation between BMI and DLI (p < 0.0001), and age was negatively correlated with DLI (p = 0.01). Analysis revealed no correlation between time-to-first DLI and BMI. Our data confirm that higher BMI is associated with increased prevalence of DLI in LVAD population, particularly in younger patients. Addressing excessive body weight in this patient cohort may significantly reduce DLI and thereby improve long-term outcomes.

SIPAT B Score Predicts Mortality in Both BTT and DT Male LVAD Patients

Introduction The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) score assesses psychosocial and behavioral risk in patients who are undergoing evaluation for heart transplant. The SIPAT score is associated with adverse outcomes including increased rates of rejection, admissions and infections post-transplant. Many Stage D heart failure patients will undergo SIPAT testing, with some receiving an LVAD as bridge to transplant (BTT) and other as destination therapy (DT). However, the role of SIPAT scores in left ventricular assist devices (LVAD) patients remains unclear based on a limited number of studies. The objective of this study assesses whether SIPAT scores were associated with increased mortality. Methods SIPAT scores were documented by a Licensed Master Social Worker for 137 LVAD patients (mean age: 50.0±13 years 35.8% female, 59.8% black)including BTT and DT (57.7%) implanted at Emory University Hospital from 2010 to 2018. The total SIPAT score is comprised of 4 subscales that represent different psychosocial domains: A - patient readiness and illness management, B - social support system, C - psychological stability and psychopathology, and D—lifestyle and substance abuse. Multivariable Cox regression models were used to examine the association of SIPAT scores with mortality. Results During a follow-up period of 1.58 years [IQR 0.8-2.87], 53 patients (38.7%) died. The mean total SIPAT score was 7.45 ±8.06, and 92.0% of patients classified as excellent-good candidates (total SIPAT score ≤20). There was no association between total SIPAT scores and mortality in the total cohort. However, the SIPAT B subscale was associated with mortality in men after adjusting for age, race, albumin, and renal function (SIPAT B *sex interaction P=0.009). Men who died had a higher mean score on the SIPAT B subscale than those who did not (2.00 ± 3.65 vs. 0.63 ± 1.63, p=0.05). Sex-stratified Cox models demonstrated that the SIPAT B subscale was associated with mortality in men (adjusted HR: 1.39, 95% CI 1.11-1.75, p=0.004); but not in women (p=0.4). Conclusions In patients with LVAD, the SIPAT B subscale was associated with an increased risk of mortality in men. These findings suggest that social support may play an even greater role for male patients with LVAD as compared to females. More research is needed to determine which factors clearly define the association between social support and mortality in the LVAD population.

Provider Perspectives on Advance Directives in Patients with Left Ventricular Assist Devices

Purpose Left ventricular assist devices (LVAD) are approved for acute and long-term support, however morbidity during device support complicates the post-operative course and may lead to earlier death in some patients. The aim of this study is to understand difficulties and opportunities for improvement in advance directive (AD) use and informed consent (IC) in the care of the LVAD population. Methods Semi-structured interviews with heart failure physicians (HFP), cardiac surgeons, and LVAD support staff were conducted at an academic institution. A single investigator experienced in semi-structured interviewing administered each interview. Recorded interviews were transcribed and coded by independent investigators; disagreements were resolved by discussion and consensus. Software for mixed methods analysis (NVIVO v12.1) was used to analyze the interviews. Results A total of 20 respondents completed interviews. Respondents disagreed on who should lead the AD discussion as HFPs (40%), LVAD coordinators (50%), and the LVAD “team” (30%) were all identified. Importantly, 50% of respondents thought that primary care doctors had inadequate expertise to lead the AD discussion. 50% of respondents cited difficulty in initiating an AD dialogue due to patients’ emotional states. Most respondents recommended expanding the AD's scope to include preferences in the event of an LVAD-specific complication. Respondents primarily described offering two choices during the IC session: palliative inotropes (90%) and VAD implantation (100%), while a minority mentioned hospice or transplant. 50% identified patient education level, and 30% identified emotional-state issues as barriers to the IC process. Respondents suggested creating a more consistent message (30%), with repeat exposures (40%), and moving toward more concrete examples as educational tools (20%) to improve the IC process. Conclusions A qualitative analysis of interviews with a range of staff identified a number of commonly held beliefs, difficulties, and possible improvements in the AD and IC process for patients considering LVAD implantation. While concern over more fundamental difficulties were expressed, multiple opportunities for improvement were identified.

Intracranial Hemorrage in Patients with Continous Flow LVAD

Purpose Patients with left ventricular assist devices (LVAD) are at high risk of cerebrovascular events, including stroke and intracranial hemorrage (ICH). There is limited data available on risk factors and outcome associated with CNI events in LVAD population. In this study the incidence of ICH, outcome and associated risk factors were evaluated. Methods 340 patients implanted with continuous-flow LVAD from the year 2012 to 2018 were included in the study. Results During this time interval, 46 patients had ICH and the incidence rate of ICH was 0.022 per patient-year. ICH patients’ mean age was 50.7 ± 11.8 years and 41 (89.1%) patients were men. The incidence of ICH was 14.3% (n=46). 15.2% of the events were hemorragic transformation after stroke, 8.7% were associated with high INR values, 13.6% developed after thrombolytic therapy for pump thrombosis and 63% were spontaneous (without any established predisposition). Traditional risk factors weren't determinative of hemorrhagic stroke events. 13.1% of ICH patients had a previous CNI event before LVAD implantation. The previous CNI event (whether an ischemic stroke or ICH) before LVAD implantation wasn't associated with postop of ICH. 76% of the spontaneous ICH patients had nonischemic cmp. This number was significantly higher than patients with ischemic origin (76% and 24% respectively p=0.047). ICH related mortality rate was 45.7%. Mortality mostly occurred in hemorrhagic transformation stroke patients (83.3%). Mortality rate was 34.5 % in spontaneous ICH patients. Death was significantly higher in ischemic cmp patients than in nonischemic population (63.6%-30.4% respectively, p=0.026) 41.4% of the spontaneous ICH patients had positive blood cultures within the previous 30 days or 7 days after the ICH event. The most frequent pathogen that caused bacteremia was gram-positive (75%) and the most frequent established pathogen was Staphylococcus aureus (41.7%). Another condition associated with spontaneous bleeding was bacteriemia due to driveline infection (75% n=9, p=0.001). The most frequent pathogen that caused bacteremia was gram-positive bacteria(75%) and the most frequent established pathogen was Staphylococcus aureus (41.7%). Conclusion ICH seen after LVAD implantation is associated with high mortality rates. Infection with positive blood cultures is a strong risk factor for ICH. Nonischemic cmp patients were found to be at higher risk.