- Email: [email protected]
Hospital to Home: LVAD Patient Management
The 16th Annual Scientific Meeting Conclusions: In a cohort of INTERMACS $4 patients deemed appropriate for implantation of partial circulatory support based on clinical and hemodynamic criteria, SHFS varied widely. SHFS (by design) does not account for hemodynamic factors likely to be important in determining and justifying the need for mechanical circulatory support. SHFS may therefore not be suitable as a selection criterion for this form of therapy. As use of assist devices migrates toward “less sick” though still severely compromised patients, there is increased need for development of tools and criteria to aid in patient selection to ensure a clinically acceptable risk/benefit ratio.
137 The Choice for Patients “Without a Choice”: Interviews With Patients Who Received a Left Ventricular Assist Device as Destination Therapy Keith M. Swetz1,2, Abigale L. Ottenberg2, Katlyn E. Cook1,2, Luke A. Mueller1, Nou Chang1, Paul S. Mueller1,2; 1Division of General Internal Medicine, Mayo Clinic, Rochester, MN; 2Program in Professionalism and Ethics, Mayo Clinic, Rochester, MN Purpose: The left ventricular assist device as destination therapy (DT) has been shown to improve clinical outcomes for appropriately selected patients with advanced heart failure. However, best outcomes require an appreciation of the burdens of DT, particularly psychosocial considerations. A qualitative research study was conducted with patients who received DT to understand their perceptions regarding post-implant care and shared decision-making before DT implantation. Methods: Ambulatory outpatients with DT were invited to participate in 45 minute individual interviews with a trained interviewer and observer. Qualitative methods were used to analyze transcripts. Results: The study included 12 patients (11 men) from the Midwestern USA with a median age 71.5 y (range, 33-78). The majority of patients were white (11), married (10) and Christian (10). Analysis revealed most patients saw DT as “their only choice” despite multidisciplinary efforts at providing informed consent. All patients identified at least one dedicated caregiver. Each patient described a unique recovery process with “ups and downs” in health status and an evolution of personal goals of care. All patients were overall “grateful” to receive DT. Challenges included psychosocial adjustment, environmental barriers due to limited local provider knowledge, and caregiver burden/fatigue. Positive aspects of recovery included symptom improvement from physiological benefits of DT and stronger interpersonal relationships. Heightened introspection and redefinition of goals were common themes identified. Conclusion: Ambulatory patients and their loved ones reported varied experiences with post-DT recovery, but commonly reported gratitude for improved functional status and a perception of improved symptom burden. These results appear congruent with reported outcomes for patients who are discharged from the hospital after DT. Recommendations for improving post-DT care include encouraging the development of patient support systems, systematizing education for community providers, and expanding respite care services. Palliative care involvement is recommended to assess patient quality of life and for ongoing assessment of goals of care given the burdens of DT. Similar analysis of patients/loved ones with prolonged hospitalization may provide further insights into other challenges of post-DT care.
138
Table. LVAD Patient Education Survey 1. Hospital staff was knowledgeable about my device. 2. The VAD Coordinators were knowledgeable about my device and sensitive to my needs. 3. The written materials I received were helpful. 4. The Video/CD I received was helpful. 5. The demonstration and hands on training was helpful. 6. The discussion about my device was helpful. 7. I know how to change from one power source to another. 8. I know how to interpret data on my device. 9. I know how to complete daily system checks and weekly equipment maintenance. 10. I know who to call in an emergency. 11. The education provided to me helped with any fears that I might have had. 12. I feel/felt very prepared for discharge.
HFSA
S43
The survey indicated staff and patients were very knowledgeable about the LVAD device and overall, patients were very prepared for discharge. The educational material was helpful; however, based on survey results, there were improvement areas for the discharge process. Examples included structured delivery of discharge instructions and extensive pre-implant education. The fundamental key to a patient’s success is based on education from referral through the outpatient clinic. Conclusion: PHI’s self management philosophy proved successful in maintaining program satisfaction and supporting patient confidence while lessening fears with discharge. Based on survey results, the program incorporated modifications such as updating LVAD education material, creating a discharge binder, and “Go Gear” demonstrations in pre-implant education. Our experience provided patients a sense of reassurance and accountability. Reinforcement of education is vital to ensuring successful self management and preparedness for discharge.
139 Successful Use of Ultrafiltration for Decompensated Heart Failure in LVAD Patients Sitaramesh Emani1, Darla Talbott2, Donald Kikta3, Yazhini Ravi2, Robert Higgins2, Pallavi Solanki1, Garrie Haas1, Chittoor Sai-Sudhakar2; 1Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; 3Internal Medicine, University Hospitals, Cleveland, OH Ultrafiltration (UF) is an effective in treating acutely decompensated heart failure (ADHF). However, studies of UF have focused on non-LVAD patients. The application of UF in decompensated patients with implantable LVADs is currently unknown despite recognized increases in morbidity in LVAD patients with ADHF. We sought to characterize parameters of ADHF-LVAD patients treated with UF at our center. A retrospective, case series analysis was performed on LVAD patients hospitalized with ADHF who underwent UF. Clinical parameters including time on UF, volume removal, weight changes, and serum lab data were recorded before and after UF. Adverse events attributable to UF were also examined, as were 30-day readmission rates. Between 2008-11 there were 10 UF sessions in 8 unique patients. One patient had UF repeated after an LVAD change-out, and one patient had UF repeated with the same LVAD. In 8/10 sessions, patients had continuous-flow devices; 4/9 had pre-existing renal insufficiency; and 5/9 had acute renal failure prior to UF. Time from LVAD implant to UF initiation ranged from 51204 days (avg 262). Table 1 shows selected changes in clinical parameters. Additionally, blood urea nitrogen decreased on average by 9; serum creatinine changed on average by 0.05; but hematocrit changed only by 0.5 on average. Weight reduction averaged 11 kgs. One patient had significant hypotension on UF, and 1 patient had a drop in pulsatility index. No readmissions for ADHF occurred through 30 days following UF. Our study suggests that UF can be used successfully on LVAD patients with ADHF. Weight loss was similar to the major clinical trial of UF in non-LVAD patients. No major adverse events were noted and renal function remained unaffected. Lasting effects to 30 days were seen, similar to previous UF trails with no readmissions in that time. UF should be considered as reasonable for LVAD patients exhibiting signs of ADHF.
Hospital to Home: LVAD Patient Management Lindsey J. Carroll, Julie H. Webster, Shelina Merali; Advanced Heart Failure Center, Piedmont Heart Institute, Atlanta, GA Purpose: Piedmont Heart Institute (PHI) successfully developed a self management philosophy guided by an education program to adequately prepare patients for discharge. A patient satisfaction survey was used to measure the quality of staff interaction, education material and patient confidence for self care. Methods: PHI carefully developed a patient education plan, to assist with a smooth transition from a controlled inpatient environment to a home setting. Inpatient staff provided bedside teaching to support learning during hospitalization. To ensure educational concepts were quantifiable, a patient satisfaction survey was developed. The survey measured quality of staff support, educational material and patient’s comfort level with daily clinical tasks and general preparedness for discharge. Results: The satisfaction survey was administered 1 week, 1 month, and 1 year post discharge.
Clinical Parameters
Hours on UF UF Volume removed (L) Weight loss (kg)
Range
Avg
52-332 1.2-8.4 2.4-24
175 3.7 11
140 New Safety Concerns With Higher Dose Statin Therapy in Heart Transplantation: Time To Panic? Stacey D. Frampton, Rami A. Alharethi, Kimberly D. Brunisholz, Benjamin D. Horne, Kyle D. Balling, Deborah Budge, Bruce B. Reid, Jen L. Nixon, Josef Stehlik, Joe Tuinei, Kismet D. Rasmusson, Melanie Everitt, William Caine, Abdallah G. Kfoury; UTAH Cardiac Transplant Program, Salt Lake City, UT Introduction: Statin therapy is standard of care in heart transplant (HT) recipients regardless of lipid levels. Yet, recent guidelines are increasingly cautionary and restrictive as to the agent and dose to be used given safety concerns when combined with calcineurin inhibitors. The goal of this study was to evaluate the safety and impact of higher dose statin (HDS) versus recommended dose statin (RDS) treatment in HT. Methods: The UTAH Cardiac Transplant Program database was queried for patients receiving RDS and HDS between 2001and 2009. HDS was defined as pravastatin O40mg, atorvastatin O20mg, simvastatin O20mg, or rosuvastatin O10mg for more than 8 weeks of therapy. Demographics, drugs and pertinent clinical and safety laboratory data were collected at baseline (3 months) and 1 year post-HT. Changes
137 The Choice for Patients “Without a Choice”: Interviews With Patients Who Received a Left Ventricular Assist Device as Destination Therapy Keith M. Swetz1,2, Abigale L. Ottenberg2, Katlyn E. Cook1,2, Luke A. Mueller1, Nou Chang1, Paul S. Mueller1,2; 1Division of General Internal Medicine, Mayo Clinic, Rochester, MN; 2Program in Professionalism and Ethics, Mayo Clinic, Rochester, MN Purpose: The left ventricular assist device as destination therapy (DT) has been shown to improve clinical outcomes for appropriately selected patients with advanced heart failure. However, best outcomes require an appreciation of the burdens of DT, particularly psychosocial considerations. A qualitative research study was conducted with patients who received DT to understand their perceptions regarding post-implant care and shared decision-making before DT implantation. Methods: Ambulatory outpatients with DT were invited to participate in 45 minute individual interviews with a trained interviewer and observer. Qualitative methods were used to analyze transcripts. Results: The study included 12 patients (11 men) from the Midwestern USA with a median age 71.5 y (range, 33-78). The majority of patients were white (11), married (10) and Christian (10). Analysis revealed most patients saw DT as “their only choice” despite multidisciplinary efforts at providing informed consent. All patients identified at least one dedicated caregiver. Each patient described a unique recovery process with “ups and downs” in health status and an evolution of personal goals of care. All patients were overall “grateful” to receive DT. Challenges included psychosocial adjustment, environmental barriers due to limited local provider knowledge, and caregiver burden/fatigue. Positive aspects of recovery included symptom improvement from physiological benefits of DT and stronger interpersonal relationships. Heightened introspection and redefinition of goals were common themes identified. Conclusion: Ambulatory patients and their loved ones reported varied experiences with post-DT recovery, but commonly reported gratitude for improved functional status and a perception of improved symptom burden. These results appear congruent with reported outcomes for patients who are discharged from the hospital after DT. Recommendations for improving post-DT care include encouraging the development of patient support systems, systematizing education for community providers, and expanding respite care services. Palliative care involvement is recommended to assess patient quality of life and for ongoing assessment of goals of care given the burdens of DT. Similar analysis of patients/loved ones with prolonged hospitalization may provide further insights into other challenges of post-DT care.
138
Table. LVAD Patient Education Survey 1. Hospital staff was knowledgeable about my device. 2. The VAD Coordinators were knowledgeable about my device and sensitive to my needs. 3. The written materials I received were helpful. 4. The Video/CD I received was helpful. 5. The demonstration and hands on training was helpful. 6. The discussion about my device was helpful. 7. I know how to change from one power source to another. 8. I know how to interpret data on my device. 9. I know how to complete daily system checks and weekly equipment maintenance. 10. I know who to call in an emergency. 11. The education provided to me helped with any fears that I might have had. 12. I feel/felt very prepared for discharge.
HFSA
S43
The survey indicated staff and patients were very knowledgeable about the LVAD device and overall, patients were very prepared for discharge. The educational material was helpful; however, based on survey results, there were improvement areas for the discharge process. Examples included structured delivery of discharge instructions and extensive pre-implant education. The fundamental key to a patient’s success is based on education from referral through the outpatient clinic. Conclusion: PHI’s self management philosophy proved successful in maintaining program satisfaction and supporting patient confidence while lessening fears with discharge. Based on survey results, the program incorporated modifications such as updating LVAD education material, creating a discharge binder, and “Go Gear” demonstrations in pre-implant education. Our experience provided patients a sense of reassurance and accountability. Reinforcement of education is vital to ensuring successful self management and preparedness for discharge.
139 Successful Use of Ultrafiltration for Decompensated Heart Failure in LVAD Patients Sitaramesh Emani1, Darla Talbott2, Donald Kikta3, Yazhini Ravi2, Robert Higgins2, Pallavi Solanki1, Garrie Haas1, Chittoor Sai-Sudhakar2; 1Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH; 2Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; 3Internal Medicine, University Hospitals, Cleveland, OH Ultrafiltration (UF) is an effective in treating acutely decompensated heart failure (ADHF). However, studies of UF have focused on non-LVAD patients. The application of UF in decompensated patients with implantable LVADs is currently unknown despite recognized increases in morbidity in LVAD patients with ADHF. We sought to characterize parameters of ADHF-LVAD patients treated with UF at our center. A retrospective, case series analysis was performed on LVAD patients hospitalized with ADHF who underwent UF. Clinical parameters including time on UF, volume removal, weight changes, and serum lab data were recorded before and after UF. Adverse events attributable to UF were also examined, as were 30-day readmission rates. Between 2008-11 there were 10 UF sessions in 8 unique patients. One patient had UF repeated after an LVAD change-out, and one patient had UF repeated with the same LVAD. In 8/10 sessions, patients had continuous-flow devices; 4/9 had pre-existing renal insufficiency; and 5/9 had acute renal failure prior to UF. Time from LVAD implant to UF initiation ranged from 51204 days (avg 262). Table 1 shows selected changes in clinical parameters. Additionally, blood urea nitrogen decreased on average by 9; serum creatinine changed on average by 0.05; but hematocrit changed only by 0.5 on average. Weight reduction averaged 11 kgs. One patient had significant hypotension on UF, and 1 patient had a drop in pulsatility index. No readmissions for ADHF occurred through 30 days following UF. Our study suggests that UF can be used successfully on LVAD patients with ADHF. Weight loss was similar to the major clinical trial of UF in non-LVAD patients. No major adverse events were noted and renal function remained unaffected. Lasting effects to 30 days were seen, similar to previous UF trails with no readmissions in that time. UF should be considered as reasonable for LVAD patients exhibiting signs of ADHF.
Hospital to Home: LVAD Patient Management Lindsey J. Carroll, Julie H. Webster, Shelina Merali; Advanced Heart Failure Center, Piedmont Heart Institute, Atlanta, GA Purpose: Piedmont Heart Institute (PHI) successfully developed a self management philosophy guided by an education program to adequately prepare patients for discharge. A patient satisfaction survey was used to measure the quality of staff interaction, education material and patient confidence for self care. Methods: PHI carefully developed a patient education plan, to assist with a smooth transition from a controlled inpatient environment to a home setting. Inpatient staff provided bedside teaching to support learning during hospitalization. To ensure educational concepts were quantifiable, a patient satisfaction survey was developed. The survey measured quality of staff support, educational material and patient’s comfort level with daily clinical tasks and general preparedness for discharge. Results: The satisfaction survey was administered 1 week, 1 month, and 1 year post discharge.
Clinical Parameters
Hours on UF UF Volume removed (L) Weight loss (kg)
Range
Avg
52-332 1.2-8.4 2.4-24
175 3.7 11
140 New Safety Concerns With Higher Dose Statin Therapy in Heart Transplantation: Time To Panic? Stacey D. Frampton, Rami A. Alharethi, Kimberly D. Brunisholz, Benjamin D. Horne, Kyle D. Balling, Deborah Budge, Bruce B. Reid, Jen L. Nixon, Josef Stehlik, Joe Tuinei, Kismet D. Rasmusson, Melanie Everitt, William Caine, Abdallah G. Kfoury; UTAH Cardiac Transplant Program, Salt Lake City, UT Introduction: Statin therapy is standard of care in heart transplant (HT) recipients regardless of lipid levels. Yet, recent guidelines are increasingly cautionary and restrictive as to the agent and dose to be used given safety concerns when combined with calcineurin inhibitors. The goal of this study was to evaluate the safety and impact of higher dose statin (HDS) versus recommended dose statin (RDS) treatment in HT. Methods: The UTAH Cardiac Transplant Program database was queried for patients receiving RDS and HDS between 2001and 2009. HDS was defined as pravastatin O40mg, atorvastatin O20mg, simvastatin O20mg, or rosuvastatin O10mg for more than 8 weeks of therapy. Demographics, drugs and pertinent clinical and safety laboratory data were collected at baseline (3 months) and 1 year post-HT. Changes