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Physician Ethical and Legal Views Regarding Deactivation of Cardiac Implantable Electrical Devices
S106 Journal of Cardiac Failure Vol. 16 No. 8S August 2010 catheterization from Jan 2000 e Dec 2008, with a diagnosis of HF due to systolic dysfunction (LVEF!40%) were included. Patients with hyponatremia (Na ! 135 mmol/L) were compared to those without hyponatremia. Descriptive statistics were used to describe patient characteristics. Results: 1056 patients were included. 948 patients had Na R 135mmol/l, while 108 patients (10.2%) had Na ! 135. Patients with Na ! 135mmol/l were older, had lower BMI, and higher HR. 40% were women and 61% had ischemic etiology of HF. The cohort included more NYHA Class III patients, with median LVEF of 26%.The hyponatremic group was associated with more beta-blocker, ACE-inhibitor, aspirin and diuretic use. Conclusion: Hyponatremia was present in over 10% of HF patients. Hyponatremic patients were older and had more severe HF. Given the new opportunities for treatment, the unique clinical characteristics should serve to heighten surveillance of hyponatremia in these high risk patients.
350 Physician Ethical and Legal Views Regarding Deactivation of Cardiac Implantable Electrical Devices Daniel B. Kramer1, Aaron S. Kesselheim2, Dan W. Brock3, William H. Maisel1; 1The Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA; 2 Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA; 3Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA Introduction: Physicians providing end-of-life care to patients with heart failure (HF) are frequently confronted with difficult decisions regarding deactivation of implantable defibrillators (ICDs) and pacemakers (PMs). Little is known about physicians’ moral views and knowledge of legal parameters concerning device deactivation and other aspects of life-sustaining interventions. Methods: A crosssectional survey was administered to 185 physicians affiliated with a single tertiary care medical center. Subjects were asked quantify their experience with withdrawing life-sustaining therapies and their comfort with discussing specific features of endof-life care. Subjects were also asked to characterize the legality of withdrawing PM and ICD therapy in specific situations. Results: Respondents were generally internists (90%), male (54.9%), age !35 (39.1%) or O65 (18.4%), and clinical attendings (69,2%). While the vast majority of physicians (89.2%) reported being comfortable discussing certain aspects of end-of-life care with their patients (ventilation, feeding tube, dialysis), physicians were significantly less comfortable discussing deactivation of ICDs and/or pacemakers (FIGURE, P ! 0.005 for all comparisons). Few had participated in deactivating either type of device (10.4% PMs, 10.6% ICDs), and deactivation of a PM in a pacemaker-dependent patient was more problematic for physicians with less clinical experience (P ! 0.005). A substantial proportion (65.4%) of physicians were unable to correctly answer a number of questions about laws that govern conduct regarding PM and ICD deactivation. Conclusions: Physicians lack important knowledge regarding the legal status of PM and ICD deactivation, and are less comfortable discussing withdrawal of cardiac electrical therapy than other life-sustaining interventions. In order to better serve HF patients with these devices at the end-of-life, initiatives are needed to better-educate physicians in this area.
349 Target Weight Guided Treatment of Acute Heart Failure Using Ultrafiltration or Usual Care: Results of a Randomized Pilot Study Cheryl Bartone, Santosh G. Menon, Dean J. Kereiakes, Thomas M. O’Brien, Wojciech Mazur, Megan McClellan, Eugene S. Chung; Heart and Vascular Center, The Christ Hospital, Cincinnati, OH Background: In the UNLOAD trial, ultrafiltration (UF) removed volume more effectively than usual care (UC). Hypothetically, UF may be superior to UC due to more sodium (Na) removal and less neurohormonal activation. We compared UF and UC in a randomized pilot trial of target weight guided therapy for acute heart failure (AHF). Methods: Sixteen patients with AHF were enrolled and target weights established prospectively, prior to randomization to UF or UC. UF patients did not receive diuretics and UC patients all treated with a furosemide drip. All urine and ultrafiltrate were collected and Na concentrations measured. Results: Baseline data and results are shown below. Mean UF rate was 162 ml/hour. The UF group produced isotonic ultrafiltrate but also higher volume of dilute urine than expected. Conclusions: In a randomized pilot study of target weight guided therapy with UF or UC, there were no differences in total volumes or Na removed, or length of stay. Isotonic fluid loss by UF was negated by very dilute urine.
LVEF, % Cr, mg/dL BNP, pg/ml LOS, hours target wt loss, lbs actual wt loss, lbs total removed volume, ml (entire group) total urine output, ml (entire group) total ultrafiltrate, ml (entire group) urine/patient/day, ml ultrafiltrate/patient/day, ml mean urine [Na], meq/L mean ultrafiltrate [Na], meq/L total removed Na/patient, meq pts with d/c Cr - admission Cr O0.3 pts with any Cr O 0.3 over baseline
Usual Care (n 5 8)
Ultrafiltration (n 5 8)
26 6 11 1.4 6 0.5 1,249 6 1609 140 6 78 20.3 6 6.6 16.3 6 7.2 110,105
22 6 8 1.9 6 0.6 942 6 986 158 6 32 16.4 6 10.5 14.4 6 7.9 107,415
110,105
45,325* 62,090
2,685 6 1759
Cr, creatinine; LOS, length of stay; * p ! 0.05
85 6 73 1,168 3 4
1,030 6 1200* 2,484 6 1258 26 6 23* 138 6 6 1,216 2 4
351 Prognostic Implications of Family History in Pediatric Left Ventricular NonCompaction Jeffrey J. Kim1, Joseph W. Rossano1, Jamie A. Decker1, Jack F. Price1, Ivan Wilmot1, Susan W. Denfield1, William J. Dreyer1, Jeffrey A. Towbin2, John L. Jefferies1; 1 Pediatric Cardiology, Texas Children’s Hospital, Houston, TX; 2Pediatric Cardiology, Cincinnati Children’s Hospital, Cincinnati, OH Introduction: Left ventricular non-compaction (LVNC) is a recently recognized cardiomyopathy characterized by excessive trabeculation of the left ventricular myocardium, myocardial dysfunction, arrhythmias, and early mortality. Although a heritable component has been recognized, the contribution of family history to prognostic implications has not been elucidated. Objectives: To examine the distribution and prognostic implications of family history in children diagnosed with isolated LVNC. Methods: A retrospective study was performed of all patients diagnosed with isolated LVNC at Texas Children’s Hospital between the years of 1990 and 2008. Results: Two hundred and forty two children were diagnosed with isolated LVNC over the study period utilizing standard diagnostic criteria. Fifty-six children (23%) had a family history of cardiomyopathy in 91 relatives, although only 14/56 (25%) had a family history of LVNC, with the remainder having a family history of DCM (27), HCM (5), or a combination of cardiomyopathy types (10). Eleven family members previously diagnosed with either HCM or DCM had echocardiograms available for review and 8 of them subsequently had their diagnoses changed to LVNC. Thirty one children (12.8%) died and 13 (5.4%) were transplanted during follow-up. Based on multivariate analylsis, patients with an existing family history of cardiomyopathy were significantly less likely to die or need cardiac transplantation
350 Physician Ethical and Legal Views Regarding Deactivation of Cardiac Implantable Electrical Devices Daniel B. Kramer1, Aaron S. Kesselheim2, Dan W. Brock3, William H. Maisel1; 1The Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, MA; 2 Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Boston, MA; 3Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA Introduction: Physicians providing end-of-life care to patients with heart failure (HF) are frequently confronted with difficult decisions regarding deactivation of implantable defibrillators (ICDs) and pacemakers (PMs). Little is known about physicians’ moral views and knowledge of legal parameters concerning device deactivation and other aspects of life-sustaining interventions. Methods: A crosssectional survey was administered to 185 physicians affiliated with a single tertiary care medical center. Subjects were asked quantify their experience with withdrawing life-sustaining therapies and their comfort with discussing specific features of endof-life care. Subjects were also asked to characterize the legality of withdrawing PM and ICD therapy in specific situations. Results: Respondents were generally internists (90%), male (54.9%), age !35 (39.1%) or O65 (18.4%), and clinical attendings (69,2%). While the vast majority of physicians (89.2%) reported being comfortable discussing certain aspects of end-of-life care with their patients (ventilation, feeding tube, dialysis), physicians were significantly less comfortable discussing deactivation of ICDs and/or pacemakers (FIGURE, P ! 0.005 for all comparisons). Few had participated in deactivating either type of device (10.4% PMs, 10.6% ICDs), and deactivation of a PM in a pacemaker-dependent patient was more problematic for physicians with less clinical experience (P ! 0.005). A substantial proportion (65.4%) of physicians were unable to correctly answer a number of questions about laws that govern conduct regarding PM and ICD deactivation. Conclusions: Physicians lack important knowledge regarding the legal status of PM and ICD deactivation, and are less comfortable discussing withdrawal of cardiac electrical therapy than other life-sustaining interventions. In order to better serve HF patients with these devices at the end-of-life, initiatives are needed to better-educate physicians in this area.
349 Target Weight Guided Treatment of Acute Heart Failure Using Ultrafiltration or Usual Care: Results of a Randomized Pilot Study Cheryl Bartone, Santosh G. Menon, Dean J. Kereiakes, Thomas M. O’Brien, Wojciech Mazur, Megan McClellan, Eugene S. Chung; Heart and Vascular Center, The Christ Hospital, Cincinnati, OH Background: In the UNLOAD trial, ultrafiltration (UF) removed volume more effectively than usual care (UC). Hypothetically, UF may be superior to UC due to more sodium (Na) removal and less neurohormonal activation. We compared UF and UC in a randomized pilot trial of target weight guided therapy for acute heart failure (AHF). Methods: Sixteen patients with AHF were enrolled and target weights established prospectively, prior to randomization to UF or UC. UF patients did not receive diuretics and UC patients all treated with a furosemide drip. All urine and ultrafiltrate were collected and Na concentrations measured. Results: Baseline data and results are shown below. Mean UF rate was 162 ml/hour. The UF group produced isotonic ultrafiltrate but also higher volume of dilute urine than expected. Conclusions: In a randomized pilot study of target weight guided therapy with UF or UC, there were no differences in total volumes or Na removed, or length of stay. Isotonic fluid loss by UF was negated by very dilute urine.
LVEF, % Cr, mg/dL BNP, pg/ml LOS, hours target wt loss, lbs actual wt loss, lbs total removed volume, ml (entire group) total urine output, ml (entire group) total ultrafiltrate, ml (entire group) urine/patient/day, ml ultrafiltrate/patient/day, ml mean urine [Na], meq/L mean ultrafiltrate [Na], meq/L total removed Na/patient, meq pts with d/c Cr - admission Cr O0.3 pts with any Cr O 0.3 over baseline
Usual Care (n 5 8)
Ultrafiltration (n 5 8)
26 6 11 1.4 6 0.5 1,249 6 1609 140 6 78 20.3 6 6.6 16.3 6 7.2 110,105
22 6 8 1.9 6 0.6 942 6 986 158 6 32 16.4 6 10.5 14.4 6 7.9 107,415
110,105
45,325* 62,090
2,685 6 1759
Cr, creatinine; LOS, length of stay; * p ! 0.05
85 6 73 1,168 3 4
1,030 6 1200* 2,484 6 1258 26 6 23* 138 6 6 1,216 2 4
351 Prognostic Implications of Family History in Pediatric Left Ventricular NonCompaction Jeffrey J. Kim1, Joseph W. Rossano1, Jamie A. Decker1, Jack F. Price1, Ivan Wilmot1, Susan W. Denfield1, William J. Dreyer1, Jeffrey A. Towbin2, John L. Jefferies1; 1 Pediatric Cardiology, Texas Children’s Hospital, Houston, TX; 2Pediatric Cardiology, Cincinnati Children’s Hospital, Cincinnati, OH Introduction: Left ventricular non-compaction (LVNC) is a recently recognized cardiomyopathy characterized by excessive trabeculation of the left ventricular myocardium, myocardial dysfunction, arrhythmias, and early mortality. Although a heritable component has been recognized, the contribution of family history to prognostic implications has not been elucidated. Objectives: To examine the distribution and prognostic implications of family history in children diagnosed with isolated LVNC. Methods: A retrospective study was performed of all patients diagnosed with isolated LVNC at Texas Children’s Hospital between the years of 1990 and 2008. Results: Two hundred and forty two children were diagnosed with isolated LVNC over the study period utilizing standard diagnostic criteria. Fifty-six children (23%) had a family history of cardiomyopathy in 91 relatives, although only 14/56 (25%) had a family history of LVNC, with the remainder having a family history of DCM (27), HCM (5), or a combination of cardiomyopathy types (10). Eleven family members previously diagnosed with either HCM or DCM had echocardiograms available for review and 8 of them subsequently had their diagnoses changed to LVNC. Thirty one children (12.8%) died and 13 (5.4%) were transplanted during follow-up. Based on multivariate analylsis, patients with an existing family history of cardiomyopathy were significantly less likely to die or need cardiac transplantation