Cost-Effectiveness of Left Ventricular Assist Devices in Ambulatory Patients With Advanced Heart Failure

Time-varying analyses of survival and outcomes in patients with HeartMate 3 left ventricular assist devices

AIMS

As patients experience longer survival on HeartMate 3 left ventricular assist devices, there is a need to characterize long-term risks of adverse outcomes more precisely. This study characterized temporal variations in risks of mortality and adverse outcomes in patients with a HeartMate 3.

METHODS AND RESULTS

From October 2015 to January 2023, 431 HeartMate 3 devices were implanted at Cleveland Clinic. Survival was estimated to 5 years post-implant. Time-varying risks of death, neurological events, gastrointestinal bleeding, device-related infections, and other adverse events were characterized using multiphase hazard modelling. Survival on HeartMate 3 at 1 and 5 years was 88% and 58%, respectively. Risk of death peaked in the first postoperative month before declining rapidly to a constant, lower hazard. Cumulative number of neurological events/patient at 1 year and 5 years was 0.13 and 0.29, respectively; risk was highest within the first postoperative week, then rapidly declined by 1 month. Cumulative number of gastrointestinal bleeding events/patient at 1 year and 5 years was 0.32 and 0.78, respectively; risk was highest within 1 week postoperatively and gradually declined to a constant risk over the first year. Device-related infections developed in 136 patients. One- and 5-year freedom from device-related infection was 77% and 45%, respectively; risk was initially low before peaking at 6 months postoperatively and then gradually declining to a steady hazard.

CONCLUSION

Long-term survival on HeartMate 3 support was favourable in a large single-centre cohort. Strategies to reduce early postoperative risk of neurological events and late risks of gastrointestinal bleeding, infections and other adverse events are needed.

Cost Effectiveness of Left Ventricular Assist Devices (LVADs) as Destination Therapy: A Systematic Review

OBJECTIVES

Left ventricular assist devices (LVADs) can extend life and improve quality of life among advanced heart failure patients ineligible for transplantation (destination therapy). High-quality evidence on the cost effectiveness of LVADs compared with optimal medical management is needed to inform policy. This study identifies economic evaluations of LVADs for destination therapy and assesses their methodological quality.

METHODS

The review followed Centre for Review and Dissemination guidelines for methods, and PRISMA standards for reporting, and was registered on PROSPERO (CRD42020158987). Six databases were searched for studies published up to October 2024. Full economic evaluations of LVADs for destination therapy were included. Two reviewers independently conducted study selection, data extraction and quality assessment using validated tools.

RESULTS

The study identified 14 economic evaluations, including 10 modelling studies. Most studies were from the US and UK. There was substantial variation in model structure, methods, and cost estimates. Only seven studies used a lifetime horizon. Resource use was typically estimated based on data from small single-centre samples. Overall quality was moderate due to key limitations such as insufficient time horizons, omitting complications and costs, and limited consideration of uncertainty. Only two studies examined severity, and none assessed cost effectiveness by patient age. Most studies found LVADs not to be cost effective compared with medical management except for two UK-based evaluations.

CONCLUSION

This review reveals important limitations in the current evidence on the cost effectiveness of LVADs as destination therapy. More comprehensive, robust evaluations are needed to inform policy decisions.

Rezafungin for suppressive therapy of Candida auris in a patient with a left ventricular assist device (LVAD)

Introduction

Invasive candidiasis is a common healthcare-associated infection with significant morbidity and mortality. Candida auris in particular has emerged as a problematic and challenging healthcare-associated infection, especially with regards to infections involving left ventricular assist devices (LVADs). There is a paucity of evidence on the best management of these particular types of infections. Rezafungin is a newly-approved echinocandin and an important new tool in the management of invasive candidiasis. We report the novel use of rezafungin for suppressive therapy in a patient with an LVAD-associated C. auris infection.

Case

The patient is a 57-year-old male with a past medical history most notable for heart failure with ischemic cardiomyopathy. The patient underwent LVAD placement and his post-LVAD placement clinical course was notable for recurrent C. auris fungemia. The patient was originally on indefinite micafungin therapy, but was eventually switched to once-weekly rezafungin as this was felt to be safer, easier, and more convenient for the patient. He did well on weekly rezafungin for about 4 months but did eventually develop breakthrough C. auris fungemia.

Conclusions

Rezafungin is a promising new antifungal in the armamentarium of drugs for treatment of invasive candidiasis, notably C. auris. Though the patient did develop a breakthrough C. auris bloodstream infection while on rezafungin therapy, his infection was well-controlled for a little over 4 months, which prevented any C. auris-related hospital admissions during that time period. This case represents the first example of rezafungin being used for an LVAD-associated C. auris infection.

Rethinking Care: Early Palliative Support for Advanced Heart Failure

Congestive heart failure (CHF) remains a major global cause of mortality, impacting millions worldwide. It is characterized by the heart's inability to pump adequate blood, leading to progressive symptoms such as dyspnea and fluid retention. This case report highlights an 87-year-old male with complex multi-system disease, including heart failure with reduced ejection fraction, chronic obstructive pulmonary disease (COPD), diabetes, chronic kidney disease, atrial fibrillation, prior intracranial hemorrhage, and multiple malignancies. Despite numerous hospitalizations for acute hypoxic respiratory failure, exacerbated by CHF, COPD, pleural effusions, and suspected hospital-acquired pneumonia, his condition continued to deteriorate. Standard treatments, including bilevel positive airway pressure, diuresis, bronchodilators, and antibiotics, provided only temporary relief, and cognitive and functional status declined. A key challenge in his care was his daughter, his sole caregiver, who faced significant emotional and financial strain. She did meet the criteria for caregiver burden. Misconceptions about hospice care contributed to her reluctance to transition away from aggressive treatment, delaying access to early palliative care and symptom management. Systemic barriers, such as gaps in insurance coverage, further compounded caregiving difficulties by limiting access to home health services and necessary support. This case underscores the critical need for early integration of palliative care in managing advanced CHF. Early involvement can improve symptom control, enhance patient comfort, and provide vital support for caregivers. Proactive discussions around the limitations of aggressive treatment, along with efforts to dispel common misconceptions about hospice care, can help reduce unnecessary hospitalizations and ensure that care remains aligned with the patient's values and goals. In applying the Institute for Healthcare Improvement's (IHI) 5Ms (medications, mentation, mobility, multi-complexity, and what matters most) model, providers are reminded to take a comprehensive, person-centered approach to geriatric care. Each domain plays a role in addressing the complex needs of older adults, but above all, focusing on what matters most helps ensure that care decisions reflect the individual's preferences, priorities, and definition of quality of life. Aligning treatment with these personal goals promotes dignity, reduces burdensome interventions, and supports more meaningful, compassionate care throughout the disease trajectory.

Weakness acquired in the cardiac intensive care unit: still the elephant in the room?

Over the past two decades, the cardiac critical care population has shifted to increasingly comorbid and elderly patients often presenting with nonprimary cardiac conditions that exacerbate underlying advanced cardiac disease. Consequently, the modern cardiac intensive care unit (CICU) patient has poor outcome regardless of left ventricular ejection fraction. Importantly, delayed liberation from organ support, independent from premorbid health status and admission severity of illness, has been associated with increased morbidity and mortality up to years post-general critical care. Although a constellation of several acquired morbidities is at play, the most prominent enactor of poor long-term outcome in this population appears to be intensive care unit acquired weakness. Although the specific burden of ICU-acquired morbidities in CICU patients is yet to be clearly defined, it seems unfathomable that patients will not accrue some sort of ICU-related morbidity. There is hence an urgent need to better establish the exact benefit and cost of resource-intensive strategies in both short- and long-term survival of the CICU patient. Consequent and standardized documentation of admission comorbidities, severity of illness indicators, relevant ICU-related complications including weakness, and long-term post-ICU morbidity outcomes can help our understanding of the disease continuum and how to better care for the CICU survivor and their families and caregivers. Given increasing budgetary pressure on healthcare systems worldwide, interventions targeting CICU patients should focus on improving patient-centred long-term outcomes in a cost-effective manner. It will require a holistic and transmural continuity of care model to meet the challenges associated with treating critically ill cardiac patients in the future.

Recent Developments in Ventricular Assist Device Therapy

The evolution of left ventricular assist devices (LVADs) from large, pulsatile systems to compact, continuous-flow pumps has significantly improved implantation outcomes and patient mobility. Minimally invasive surgical techniques have emerged that offer reduced morbidity and enhanced recovery for LVAD recipients. Innovations in wireless power transfer technologies aim to mitigate driveline-related complications, enhancing patient safety and quality of life. Pediatric ventricular assist devices (VADs) remain a critical unmet need; challenges in developing pediatric VADs include device sizing and managing congenital heart disease. Advances in LVAD technology adapted for use in right ventricular assist devices (RVADs) make possible the effective management of right ventricular failure in patients with acute cardiac conditions or congenital heart defects. To address disparities in mechanical circulatory support (MCS) access, cost-effective VAD designs have been developed internationally. The Vitalmex device from Mexico City combines pulsatile-flow technology with a paracorporeal design, utilizing cost-effective materials like silicone-elastic and titanium, and features a reusable pump housing to minimize manufacturing and operational costs. Romanian researchers have used advanced mathematical modeling and three-dimensional (3D) printing to produce a rim-driven, hubless axial-flow pump, achieving efficient blood flow with a compact design that includes a wireless power supply to reduce infection risk. In conclusion, MCS continues to advance with technological innovation and global collaboration. Ongoing efforts are essential to optimize outcomes, expand indications, and improve access to life-saving therapies worldwide.

Durable left ventricular assist devices: a contemporary review of their benefits and drawbacks

INTRODUCTION

Heart transplantation, the gold standard for end-stage cardiomyopathy, is hindered by donor shortages and clinical deterioration. Left ventricular assist devices (LVADs) have emerged as crucial alternatives, stabilizing hemodynamics, reversing end-organ damage, and enabling patient discharge. Significant engineering advancements and iterative improvements have since produced devices capable of rivaling heart transplantation in early survival potential. This review serves to provide an overview of LVAD technology, an understanding of current device limitations, and preview new technologies being developed to address them.

AREAS COVERED

This manuscript reviews the evolution of LVAD technology, discussing its benefits, drawbacks, and contemporary outcomes. It will detail the progression, current state, and future directions of LVAD technology, emphasizing its pivotal role in managing advanced heart failure.

EXPERT OPINION

The modern day LVAD has significantly extended the lifespan of patients with end-stage heart failure. However, adverse events remain abound and will be the focus of the next generation of devices. A burgeoning pipline of new technologies abound and preview the possibilities of a sustainable solution to a devastating disease.

Left Ventricular Assist Device in Advanced Refractory Heart Failure: A Comprehensive Review of Patient Selection, Surgical Approaches, Complications and Future Perspectives

The management of advanced heart failure (HF) has long posed significant challenges due to its complex and chronic nature. Heart transplantation, while effective, is not always feasible due to the limited availability of donor organs. In this context, long term mechanical circulatory support and mainly left ventricular assist devices (LVADs) have emerged as a vital intervention to fill this gap. LVAD superiority compared to medical therapy for some patients in advanced heart failure has been demonstrated either as a bridge to transplantation or as destination therapy. This literature review provides a comprehensive overview of the effectiveness, challenges, and advancements in the use of LVADs for treating advanced heart failure. It evaluates clinical outcomes associated with LVAD therapy, focusing on survival rates and quality of life improvements. The review synthesizes findings from recent studies, highlighting both the benefits and complications of LVAD implantation, such as infectious risk, thromboembolic events, hemorrhage and device malfunction. Additionally, it explores the latest technological and biomedical advancements in LVAD design, including innovations in biocompatibility, miniaturization, and power management. By examining current research, this review aims to elucidate how LVADs are transforming heart failure treatment and to offer insights into future directions for clinical practice and research.

Economic aspects of long-term left ventricular assist device treatment for chronic heart failure

AIMS

Technological advances and the current shortage of donor organs have contributed to an increase in the number of left ventricular assist device (LVAD) implantations in patients with end-stage heart failure. Demographic change and medical progress might raise the number of these patients, resulting in a further increase in the number of LVAD implantations. The aim of this study was to evaluate the long-term costs of LVAD therapy and identify diagnoses resulting in expensive stays.

METHODS AND RESULTS

In this retrospective analysis of prospectively collected data, all patients after implantation of a second- or third-generation LVAD by 31 March 2022 were included. In addition to demographic and survival data, revenues and case mix points were determined for each patient. Of the 163 patients included, 75.5% were male. The mean age at LVAD implantation was 52 ± 14 years. The mean survival was 1458 ± 127 days. During follow-up, the total inpatient treatment time per patient was 70 ± 87 days. The average duration of outpatient treatment was 55.1%, based on the total duration of support. The average revenue per patient for the implant stay was $193 192.35 ± $111 801.29, for inpatient readmissions $52 068.96 ± $116 630.00, and for outpatient care $53 195.94 ± $62 363.53.

CONCLUSIONS

LVAD implantation in patients with end-stage heart failure leads to improved survival but a significant increase in treatment costs. Further multi-centre studies are necessary in order to be able to assess the effects of long-term LVAD treatment on the healthcare system.

Clinical and cost-effectiveness of left ventricular assist devices as destination therapy for advanced heart failure: systematic review and economic evaluation

Background

Selected patients with advanced heart failure ineligible for heart transplantation could benefit from left ventricular assist device therapy as 'destination therapy'. There is evidence of the efficacy of destination therapy; however, it is not currently commissioned within the United Kingdom National Health Service due to the lack of economic evidence.

Objective

What is the clinical and cost-effectiveness of a left ventricular assist device compared to medical management for patients with advanced heart failure ineligible for heart transplantation (destination therapy)?

Methods

A systematic review of evidence on the clinical and cost-effectiveness of left ventricular assist devices as destination therapy was undertaken including, where feasible, a network meta-analysis to provide an indirect estimate of the relative effectiveness of currently available left ventricular assist devices compared to medical management. For the systematic reviews, data sources searched (up to 11 January 2022) were Cochrane CENTRAL, MEDLINE and EMBASE via Ovid for primary studies, and Epistemonikos and Cochrane Database of Systematic Reviews for relevant systematic reviews. Trial registers were also searched, along with data and reports from intervention-specific registries. Economic studies were identified in EconLit, CEA registry and the NHS Economic Evaluation Database (NHS EED). The searches were supplemented by checking reference lists of included studies. An economic model (Markov) was developed to estimate the cost-effectiveness of left ventricular assist devices compared to medical management from the United Kingdom National Health Service/personal social service perspective. Deterministic and probabilistic sensitivity analyses were conducted to explore uncertainties. Where possible, all analyses focused on the only currently available left ventricular assist device (HeartMate 3TM, Abbott, Chicago, IL, USA) in the United Kingdom.

Results

The clinical effectiveness review included 134 studies (240 articles). There were no studies directly comparing HeartMate 3 and medical management (a randomised trial is ongoing). The currently available left ventricular assist device improves patient survival and reduces stroke rates and complications compared to earlier devices and relative to medical management. For example, survival at 24 months is 77% with the HeartMate 3 device compared to 59% with the HeartMate II (MOMENTUM 3 trial). An indirect comparison demonstrated a reduction in mortality compared to medical management [relative risk of death 0.25 (95% confidence interval 0.13 to 0.47); 24 months; this study]. The cost-effectiveness review included 5 cost analyses and 14 economic evaluations covering different generations of devices and with different perspectives. The reported incremental costs per quality-adjusted life-year gained compared to medical management were lower for later generations of devices [as low as £46,207 (2019 prices; United Kingdom perspective; time horizon at least 5 years)]. The economic evaluation used different approaches to obtain the relative effects of current left ventricular assist devices compared to medical management from the United Kingdom National Health Service/personal social service perspective. All gave similar incremental cost-effectiveness ratios of £53,496-58,244 per quality-adjusted life-year gained - lifetime horizon. Model outputs were sensitive to parameter estimates relating to medical management. The findings did not materially differ on exploratory subgroup analyses based on the severity of heart failure.

Limitations

There was no direct evidence comparing the clinical effectiveness of HeartMate 3 to medical management. Indirect comparisons made were based on limited data from heterogeneous studies regarding the severity of heart failure (Interagency Registry for Mechanically Assisted Circulatory Support score distribution) and possible for survival only. Furthermore, the cost of medical management of advanced heart failure in the United Kingdom is not clear.

Conclusions

Using cost-effectiveness criteria applied in the United Kingdom, left ventricular assist devices compared to medical management for patients with advanced heart failure ineligible for heart transplant may not be cost-effective. When available, data from the ongoing evaluation of HeartMate 3 compared to medical management can be used to update cost-effectiveness estimates. An audit of the costs of medical management in the United Kingdom is required to further decrease uncertainty in the economic evaluation.

Study registration

This study is registered as PROSPERO CRD42020158987.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128996) and is published in full in Health Technology Assessment; Vol. 28, No. 38. See the NIHR Funding and Awards website for further award information.

"Durable left ventricular assist devices as a bridge to transplantation in The Old and The New World"

Heart transplantation remains the gold standard treatment for end-stage heart failure patients without contraindications. However, limited donor availability and long wait times have created a need for left ventricular assist devices (LVAD) to be used as a bridge to transplantation in appropriately selected patients. Improvements in LVAD technology have resulted in improved short- and long-term outcomes, further supporting the use of these devices for a bridge-to-transplant (BTT) indication. LVAD utilization as BTT exhibits notable disparities worldwide, mainly due to variations in organ availability, allocation policies, and financial constraints. Although Europe has experienced a consistent increase in the use of LVAD for this purpose, the United Network for Organ Sharing 2018 policy amendment resulted in a significant reduction in the number of LVADs used for BTT in the US. To overcome this issue, modifications in the US allocation policy to consider factors such as days on device support, age, and type of complications may be necessary to potentially increase implantation rates.The authors provide an overview comparing the current state of heart transplantation in the US and Europe, with a particular focus on how distinct allocation policies and organ availability impact medical practices. Additionally, the review will examine critical aspects ranging from patient selection and pre-implantation optimization to post-transplant outcomes.

Hospital Readmissions in Patients Supported with Durable Centrifugal-Flow Left Ventricular Assist Devices

Background: Centrifugal-flow left ventricular assist devices (CF-LVADs) have improved morbidity and mortality for their recipients. Hospital readmissions remain common, negatively impacting quality of life and survival. We sought to identify risk factors associated with hospital readmissions among patients with CF-LVADs. Methods: Consecutive patients receiving a CF-LVAD between February 2011 and March 2021 were retrospectively evaluated using prospectively maintained institutional databases. Hospital readmissions within three years post-LVAD implantation were dichotomized into heart failure (HF)/LVAD-related or non-HF/LVAD-related readmissions. Multivariable Cox regression models augmented using a machine learning algorithm, the least absolute shrinkage and selection operator (LASSO) method, for variable selection were used to estimate associations between HF/LVAD-related readmissions and pre-, intra- and post-operative clinical variables. Results: A total of 204 CF-LVAD recipients were included, of which 138 (67.7%) had at least one HF/LVAD-related readmission. HF/LVAD-related readmissions accounted for 74.4% (436/586) of total readmissions. The main reasons for HF/LVAD-related readmissions were major bleeding, major infection, HF exacerbation, and neurological dysfunction. Using pre-LVAD variables, HF/LVAD-related readmissions were associated with substance use, previous cardiac surgery, HF duration, pre-LVAD inotrope dependence, percutaneous LVAD/VA-ECMO support, LVAD type, and the left ventricular ejection fraction in multivariable analysis (Harrell's concordance c-statistic; 0.629). After adding intra- and post-operative variables in the multivariable model, LVAD implant hospitalization length of stay was an additional predictor of readmission. Conclusions: Using machine learning-based techniques, we generated models identifying pre-, intra-, and post-operative variables associated with a higher likelihood of rehospitalizations among patients on CF-LVAD support. These models could provide guidance in identifying patients with increased readmission risk for whom clinical strategies to mitigate this risk may further improve LVAD recipient outcomes.

The economics of heart failure care

Heart failure (HF) poses a significant economic burden in the US, with costs projected to reach $70 billion by 2030. Cost-effectiveness analyses play a pivotal role in assessing the economic value of HF therapies. In this review, we overview the cost-effectiveness of HF therapies and discuss ways to improve patient access. Based on current costs, guideline directed medical therapies for HF with reduced ejection fraction provide high economic value except for sodium-glucose cotransporter-2 inhibitors, which provide intermediate economic value. Combining therapy with the four pillars of medical therapy also has intermediate economic value, with incremental cost-effectiveness ratios ranging from $73,000 to $98,500/ quality adjusted life-years. High economic value procedures include cardiac resynchronization devices, implantable cardioverter-defibrillators, and coronary artery bypass surgery. In contrast, advanced HF therapies have previously demonstrated intermediate to low economic value, but newer data appear more favorable. Given the affordability challenges of HF therapies, additional efforts are needed to ensure optimal care for patients. The recent Inflation Reduction Act contains provisions to reform policy pertaining to drug price negotiation and out-of-pocket spending, as well as measures to increase access to existing programs, including the Medicare low-income subsidy. On a patient level, it is also important to encourage patient and physician awareness and discussions surrounding medical costs. Overall, a broad approach to improving available therapies and access to care is needed to reduce the growing clinical and economic morbidity of HF.

The Cost-effectiveness of Transplanting Hearts From Hepatitis C-infected Donors Into Uninfected Recipients

BACKGROUND

The DONATE HCV trial demonstrated the safety and efficacy of transplanting hearts from hepatitis C viremic (HCV+) donors. In this report, we examine the cost-effectiveness and impact of universal HCV+ heart donor eligibility in the United States on transplant waitlist time and life expectancy.

METHODS

We developed a microsimulation model to compare 2 waitlist strategies for heart transplant candidates in 2018: (1) status quo (SQ) and (2) SQ plus HCV+ donors (SQ + HCV). From the DONATE HCV trial and published national datasets, we modeled mean age (53 years), male sex (75%), probabilities of waitlist mortality (0.01-0.10/month) and transplant (0.03-0.21/month) stratified by medical urgency, and posttransplant mortality (0.003-0.052/month). We assumed a 23% increase in transplant volume with SQ + HCV compared with SQ. Costs (2018 United States dollar) included waitlist care ($2200-190 000/month), transplant ($213 400), 4-wk HCV treatment ($26 000), and posttransplant care ($2500-11 300/month). We projected waitlist time, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs [$/QALY, discounted 3%/year]; threshold ≤$100 000/QALY).

RESULTS

Compared with SQ, SQ + HCV decreased waitlist time from 8.7 to 6.7 months, increased undiscounted life expectancy from 8.9 to 9.2 QALYs, and increased discounted lifetime costs from $671 400/person to $690 000/person. Four-week HCV treatment comprised 0.5% of lifetime costs. The ICER of SQ + HCV compared with SQ was $74 100/QALY and remained ≤$100 000/QALY with up to 30% increases in transplant and posttransplant costs.

CONCLUSIONS

Transplanting hearts from HCV-infected donors could decrease waitlist times, increase life expectancy, and be cost-effective. These findings were robust within the context of current high HCV treatment costs.

Review of heart transplantation from hepatitis C-positive donors

Significant scarcity of a donor pool exists for heart transplantation (HT) as the prevalence of patients with end-stage refractory heart failure is increasing exceptionally. With the discovery of effective direct-acting antiviral and favorable short-term outcomes following HT, the hearts from hepatitis C virus (HCV) patient are being utilized to increase the donor pool. Short-term outcomes with regards to graft function, coronary artery vasculopathy, and kidney and liver disease is comparable in HCV-negative recipients undergoing HT from HCV-positive donors compared to HCV-negative donors. A significant high incidence of donor-derived HCV transmission was observed with great success of achieving sustained viral response with the use of direct-acting antivirals. By accepting HCV-positive organs, the donor pool has expanded with younger donors, a shorter waitlist time, and a reduction in waitlist mortality. However, the long-term outcomes and impact of specific HCV genotypes remains to be seen. We reviewed the current literature on HT from HCV-positive donors.

Incremental cost-effectiveness of extracorporeal membranous oxygenation as a bridge to cardiac transplant or left ventricular assist device placement in patients with refractory cardiogenic shock

Objective

Emerging literature has described using venoarterial extracorporeal membranous oxygenation (ECMO) as a bridge to transplant or left ventricular assist device (LVAD) placement. We sought to identify the incremental cost-effectiveness ratio (ICER) of ECMO used as a bridge to cardiac transplant or LVAD.

Methods

Patients with refractory cardiogenic shock who received venoarterial ECMO and were bridged to either cardiac transplant (n = 7) or a HeartMate 3 LVAD (n = 6) placement were included. Markov modeling was used, comparing ECMO bridging with non–ECMO-bridged patients. Cohorts entered the model alive and at every 1-year cycle, were exposed to risk of death, and ran forward for 20 years after transplant or LVAD.

Results

Patients bridged with ECMO to cardiac transplant were stratified as group 1 whereas those bridged with ECMO to LVAD were stratified as group 2. The average ECMO run was 3 days in group 1 versus 11 days in group 2. Among group 1 patients, the ICER was $246,629 but was paired with a longer life expectancy. The ICER of group 2 patients was –$107,088 and was not paired with a longer life expectancy. The average inpatient cost for group 1 was found to be $636,023 versus $769,471 for group 2 patients. The average inpatient costs for patients not bridged to ECMO who received cardiac transplant or LVAD was $538,928 and $325,242, respectively.

Conclusions

Using ECMO to bridge to transplant or LVAD placement is not cost effective. However, patients bridged to transplant are paired with longer life expectancy in contrast to patients bridged to LVAD.

Cost-effectiveness of a centrifugal-flow pump for patients with advanced heart failure in Argentina

Background

Centrifugal-flow pumps are novel treatment options for patients with advanced heart failure (HF). This study estimated the incremental cost-effectiveness ratio (ICER) of centrifugal-flow pumps for patients with advanced HF in Argentina.

Methods

Two Markov models were developed to estimate the cost-effectiveness of a centrifugal-flow pump as destination therapy (DT) in patients with contraindication for heart transplantation, and as bridge-to-transplant (BTT), with a lifetime horizon using the third-party payer Social Security (SS) and Private Sector (PS) perspectives. Clinical, epidemiological, and quality-adjusted life years (QALY) parameters were retrieved from the literature. Direct medical costs were estimated through a micro-costing approach (exchange rate USD 1 = ARS 59.95).

Results

The centrifugal-flow pump as a DT increased the per patient QALYs by 3.5 and costs by ARS 8.1 million in both the SS and PS, with an ICER of ARS 2.3 million per QALY. Corresponding values for a centrifugal-flow pump as BTT were 0.74 QALYs and more than ARS 8 million, yielding ICERs of ARS 11 million per QALY (highly dependent on waiting times). For the 1, 3, and 5 GDP per QALY thresholds, the probability of a centrifugal-flow pump to be cost-effective for DT/BTT was around 2%/0%, 40%/0%, and 80%/1%, respectively.

Conclusion

The centrifugal-flow pump prolongs life and improves the quality of life at significantly higher costs. As in Argentina there is no current explicit cost-effectiveness threshold, the final decision on reimbursement will depend on the willingness to pay in each subsector. Nevertheless, the centrifugal-flow pump as a DT was more cost-effective than as a BTT.

Concept, Design, and Early Prototyping of a Low-Cost, Minimally Invasive, Fully Implantable Left Ventricular Assist Device

Despite evidence associating the use of mechanical circulatory support (MCS) devices with increased survival and quality of life in patients with advanced heart failure (HF), significant complications and high costs limit their clinical use. We aimed to design an innovative MCS device to address three important needs: low cost, minimally invasive implantation techniques, and low risk of infection. We used mathematical modeling to calculate the pump characteristics to deliver variable flows at different pump diameters, turbomachinery design software CFturbo (2020 R2.4 CFturbo GmbH, Dresden, Germany) to create the conceptual design of the pump, computational fluid dynamics analysis with Solidworks Flow Simulation to in silico test pump performance, Solidworks (Dassault Systèmes SolidWorks Corporation, Waltham, MA, USA) to further refine the design, 3D printing with polycarbonate filament for the initial prototype, and a stereolithography printer (Form 2, Formlabs, Somerville, MA, USA) for the second variant materialization. We present the concept, design, and early prototyping of a low-cost, minimally invasive, fully implantable in a subcutaneous pocket MCS device for long-term use and partial support in patients with advanced HF which unloads the left heart into the arterial system containing a rim-driven, hubless axial-flow pump and the wireless transmission of energy. We describe a low-cost, fully implantable, low-invasive, wireless power transmission left ventricular assist device that has the potential to address patients with advanced HF with higher impact, especially in developing countries. In vitro testing will provide input for further optimization of the device before proceeding to a completely functional prototype that can be implanted in animals.

Intravenous administration of umbilical cord lining stem cells in left ventricular assist device recipient: Rationale and design of the uSTOP LVAD BLEED pilot study

Background

Left ventricular assist device (LVAD) implantation provides a robust survival advantage, however despite improvements in mortality, the adverse event burden of durable mechanical circulatory support remains high. Bleeding complications are one such significant complication. The uSTOP LVAD BLEED (Utilization of umbilical cord lining Stem cells TO Prevent LVAD associated angiodysplastic BLEEDing) pilot study is designed to evaluate the safety and tolerability of escalating doses of umbilical cord lining stem cells (ULSCs) in LVAD recipients to ameliorate the dysregulation of angiogenic factors seen in this population.

Design

This Phase Ia single-ascending dose pilot study will evaluate the IV administration of ULSCs in stable out-patients supported with an LVAD. In a 3 + 3 design, a maximum of 18 patients will receive an IV infusion of ULSCs.

Main outcome measures

The primary endpoints are safety and tolerability, secondary exploratory endpoints will include biomarker evaluation of angiogenic dysregulation.

Summary

This represents a novel cell type and route of administration in this population, while collecting initial data regarding the magnitude and duration of effects of cell therapy, and assessing the possibility of decreasing bleeding by a strategy of vascular stabilization.

Clinical trial registration

ClinicalTrials.gov Identifier: NCT04811261. https://clinicaltrials.gov/ct2/show/NCT04811261.

Economic Issues in Heart Failure in the United States

The cost of heart failure care is high owing to the cost of hospitalization and chronic treatments. Heart failure treatments vary in their benefit and cost. The cost effectiveness of therapies can be determined by comparing the cost of treatment required to obtain a certain benefit, often defined as an increase in 1 year of life. This review was sponsored by the Heart Failure Society of America and describes the growing economic burden of heart failure for patients and the health care system in the United States. It also provides a summary of the cost effectiveness of drugs, devices, diagnostic tests, hospital care, and transitions of care for patients with heart failure. Many medications that are no longer under patent are inexpensive and highly cost-effective. These include angiotensin-converting enzyme inhibitors, beta-blockers and mineralocorticoid receptor antagonists. In contrast, more recently developed medications and devices, vary in cost effectiveness, and often have high out-of-pocket costs for patients.

Twelfth Interagency Registry for Mechanically Assisted Circulatory Support Report: Readmissions After Left Ventricular Assist Device

The twelfth annual report from The Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) highlights outcomes for 26 688 continuous-flow left ventricular assist device (LVAD) patients over the past decade (2011-2020). In 2020, we observed the largest drop in yearly LVAD implant volumes since the registry's inception, which reflects the effects of the COVID-19 pandemic on cardiac surgical volumes in the United States. The 2018 heart transplant allocation policy change in the United States continues to affect LVAD implantation volumes and device strategy, with 78.1% of patients now receiving LVAD implants as destination therapy. Despite an older and sicker patient cohort, survival in the recent era (2016-2020) at 1 and 2 years continues to improve at 82.8% and 74.1%. Patient adverse event profile has also improved in the recent era, with significant reductions in stroke, gastrointestinal bleeding, infection, and device malfunction/pump thrombosis. Finally, we review the burden of readmissions after LVAD implant and highlight an opportunity to improve patient outcomes by reducing this frequent and vexing problem.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

A clinical and cost-effectiveness analysis of the HeartMate 3 left ventricular assist device for transplant-ineligible patients: A United Kingdom perspective

BACKGROUND

The clinical and cost-effectiveness of left ventricular assist device (LVAD) therapy for patients with advanced heart failure (HF) who are ineligible for heart transplantation is debated in the UK. This study develops an indirect comparison between the fully magnetically levitated HeartMate 3 (HM 3) LVAD and medical therapy (MT) to evaluate expected clinical and cost-effectiveness in the UK National Health Service (NHS) context.

METHODS

We performed an economic analysis comparing the HM3 pump against the HeartMate II LVAD (MOMENTUM 3), and then another analysis comparing MT with the first- and second-generation HeartMate XVE pump LVAD and HeartMate II LVAD for the same patient population (REMATCH and ROADMAP, respectively). By bridging those 2 analyses, an indirect comparison between HM3 and MT in the form of a network meta-analysis was developed. A literature search was performed to select the most appropriate pair of studies for this purpose. Outcomes were adjusted to produce Kaplan-Meier curves for the cost-effectiveness evaluation by using a decision-analytic model. Data were extrapolated linearly over a 5-year time horizon. Uncertainty and additional scenarios were addressed by one-way and probabilistic sensitivity analysis. Local costs and health utility were used from England, thereby representing the UK context.

RESULTS

The incremental cost-effectiveness ratio (ICER) for LVAD vs MT in transplant ineligible patients with advanced HF was estimated to be £47,361 per quality-adjusted life year gained, with a 97.1% probability of being cost-effective at £50,000. In a subgroup of patients who are inotropic therapy dependent (INTERMACS 1-3 severity profile), the ICER was £45,616, while for a population with less-ill ambulatory HF (INTERMACS profile 4-7) the ICER changed to £64,051.

CONCLUSIONS

This study provides evidence that HM3 LVAD therapy in advanced HF patients ineligible for heart transplantation may be cost-effective compared to MT in the NHS UK-England context. The ICER is lowest for patients dependent on inotropic support, but exceeds the willingness to pay threshold of £50,000 in ambulatory noninotropic therapy dependent advanced HF patients.

Evaluation of Medicare Claims for the Development of Heart Failure Diagnostics

BACKGROUND

Although claims data provide a large and efficient source of clinical events, validation is needed prior to use in heart failure (HF) diagnostic development.

METHODS AND RESULTS

Data from the Multisensor Chronic Evaluations in Ambulatory Heart Failure Patients (MultiSENSE) study, used to create the HeartLogic HF diagnostic, were linked with fee-for-service (FFS) Medicare claims. Events were matched by patient ID and date, and agreement was calculated between claims primary HF diagnosis codes and study event adjudication. HF events (HFEs) were defined as inpatient visits, or outpatient visits with intravenous decongestive therapy. Diagnostic performance was measured as HFE-detection sensitivity and false-positive rate (FPR). Linkage of 791 MultiSENSE subjects returned 320 FFS patients with an average follow-up duration of 0.94 years. Although study and claims deaths matched exactly (n = 14), matching was imperfect between study hospitalizations and acute inpatient claims events. Of 239 total events, 165 study hospitalizations (69%) matched inpatient claims events, 28 hospitalizations matched outpatient claims events (12%), 14 hospitalizations were study-unique (6%), and 32 inpatient events were claims-unique (13%). Inpatient HF classification had substantial agreement with study adjudication (κ = 0.823). Diagnostic performance was not different between claims and study events (sensitivity = 75.6% vs 77.6% and FPR = 1.539 vs 1.528 alerts/patient-year). HeartLogic-detected events contributed to > 90% of the HFE costs used for evaluation.

CONCLUSIONS

Acceptable event matching, good agreement of claims diagnostic codes with adjudication, and equivalent diagnostic performance support the validity of using claims for HF diagnostic development.

Comparison of household income in in-hospital outcomes after implantation of left ventricular assist device

INTRODUCTION

Due to the inability to keep up with the demand for heart transplantation, there is an increased utilization of left ventricular assist devices (LVAD). However, paucity of data exists regarding the association of household income with in-hospital outcomes after LVAD implantation.

METHODS

Retrospective cohort study using the NIS to identify all patients ⩾18 years who underwent LVAD implantation from 2011 to 2017. Statistical analysis was performed comparing low household income (⩽50th percentile) and high income (>50th percentile).

RESULTS

A total of 25,503 patients underwent LVAD implantation. The low-income group represented 53% and the high-income group corresponded to 47% of the entire cohort. The low-income group was found to be younger (mean age 55 ± 14 vs 58 ± 14 years), higher proportion of females (24% vs 22%), and higher proportion of blacks (32% vs 16%, p < 0.001 for all). The low-income group was found to have higher prevalence of hypertension, chronic pulmonary disease, smoking, dyslipidemia, obesity, and pulmonary hypertension (p < 0.001 for all). However, the high-income cohort had higher rate of atrial tachyarrhythmias and end-stage renal disease (p < 0.001). During hospitalization, patients in the high-income group had increased rates of ischemic stroke, acute kidney injury, acute coronary syndrome, bleeding, and need of extracorporeal membrane oxygenation (p < 0.001 for all). We found that the unadjusted mortality had an OR 1.30 (CI 1.21-1.41, p < 0.001) and adjusted mortality of OR 1.14 (CI 1.05-1.23, p = 0.002).

CONCLUSION

In patients undergoing LVAD implantation nationwide, low-income was associated with increased comorbidity burden, younger age, and fewer in-hospital complications and all-cause mortality.

A varied approach to left ventricular assist device follow-up improves cost-effectiveness

BACKGROUND

Left ventricular assist device (LVAD) implantation improves outcomes in advanced heart failure, however, the optimal frequency of outpatient assessments to improve cost-effectiveness and potentially avert readmissions is unclear.

METHODS

To test if varying the frequency of follow-up after LVAD implantation reduces readmissions and improves cost-effectiveness, a less intensive follow-up (LIFU) strategy with scheduled visits at 1 month and then every 6 months was compared to an intensive follow-up (IFU) group with scheduled visits at 1, 2, and 4 weeks, and then every 3 months post-implant. We developed a decision-tree model to evaluate the cost-effectiveness of different follow-up schedules at 3, 6, and 12-months. The readmission rates for LIFU and IFU, along with the associated costs, were estimated using data from the IBM MarketScan Commercial Claims Databases (2015-2018). A total of 349 patients were enrolled, with 193 and 156 in the IFU and LIFU groups.

RESULTS

Patients with IFU were found to have a lower risk for readmission at 3 months (HR: 0.69, 95% confidence interval (CI): 0.60-0.79), but this difference diminished overtime at 6 months (HR: 0.84, 95% CI: 0.73-0.96) and 12 months (HR: 0.94, 95% CI: 0.83-1.06). The incremental net benefit of IFU, when compared with LIFU, is greatest in the first 3 months and also diminishes over time (3 months: $19616, 6 months $9257, 12 months $717).

CONCLUSIONS

An initial IFU strategy, followed by a period of de-escalation at the 6-month post-implant mark in lower-risk patients, may be a more cost-effective strategy to provide follow-up care while not predisposing patients to a higher risk of readmission.

Clinical findings associated with incomplete hemodynamic left ventricular unloading in patients with a left ventricular assist device

INTRODUCTION AND OBJECTIVES

The effect of a centrifugal continuous-flow left ventricular assist device (cfLVAD) on hemodynamic left ventricular unloading (HLVU) and the clinical conditions that interfere with hemodynamic optimization are not well defined.

METHODS

We retrospectively evaluated the likelihood of incomplete HLVU, defined as high pulmonary capillary wedge pressure (hPCWP)> 15mmHg in 104 ambulatory cfLVAD patients when the current standard recommendations for cfLVAD rotor speed setting were applied. We also evaluated the ability of clinical, hemodynamic and echocardiographic variables to predict hPCWP in ambulatory cfLVAD patients.

RESULTS

Twenty-eight percent of the patients showed hPCWP. The variables associated with a higher risk of hPCWP were age, central venous pressure, absence of treatment with renin-angiotensin-aldosterone system inhibitors, and brain natriuretic peptide levels. Patients with optimal HLVU had a 15.2±14.7% decrease in postoperative indexed left ventricular end-diastolic diameter compared with 8.9±11.8% in the group with hPCWP (P=.041). Independent predictors of hPCWP included brain natriuretic peptide and age. Brain natriuretic peptide <300 pg/mL predicted freedom from hPCWP with a negative predictive value of 86% (P <.0001).

CONCLUSIONS

An optimal HLVU can be achieved in up to 72% of the ambulatory cfLVAD patients when the current standard recommendations for rotor speed setting are applied. Age, central venous pressure and therapy with renin-angiotensin-aldosteron system inhibitors had a substantial effect on achieving this goal. Brain natriuretic peptide levels and the magnitude of reverse left ventricular remodeling seem to be useful noninvasive tools to evaluate HLVU in patients with functioning cfLVAD.

Utilization of Left Ventricular Assist Device for Congestive Heart Failure: Inputs on Demographic and Hospital Characterization From Nationwide Inpatient Sample

Objectives The first goal of the study is to provide a descriptive overview of the utilization of left ventricular assist device (LVAD) for the treatment of congestive heart failure (CHF) and determine the rates of LVAD use stratified by patients' demographic and hospitals' characteristics in the United States. Next, is to measure the hospitalization outcomes of length of stay (LOS) and cost in inpatients managed with LVAD. Methods We conducted a cross-sectional study using the nationwide inpatient sample and included 184,115 patients (age ≥65 years) with a primary discharge diagnosis of hypertensive and non-hypertensive CHF and was further classified by inpatients who were managed with LVAD. We compared the distributions of demographic and hospital characteristics in CHF inpatients with versus without LVAD by performing Pearson's chi-square test for categorical variables, and independent sample t-test for continuous variables. Results The inpatient utilization of LVAD was 0.93% (1690 out of 184,115) in CHF patients. The LVAD cohort were younger compared to non-LVAD group (mean age, 69.9 years vs. 79.4 years). The utilization rate of LVAD was also almost four times higher in males (1.50%) compared to females (0.36%). Although whites (78.5%) accounted for majority of LVAD recipients, the rate of LVAD utilization was highest in blacks (1.04%) and lowest in Hispanics (0.58%) with whites having utilization rate of 0.89%. Medicare was the dominant primary payer to cover the LVAD inpatients (91.1%), though the rate of LVAD utilization is highest in private (2.22%) and lowest in those covered by public insurance (medicaid/medicare). CHF patients in public hospitals (1.79%) were more than twice more likely to receive LVAD than in private hospitals (0.83%) due to higher utilization rate. LVAD utilization rate was approximately 55 times higher in teaching hospitals (1.67%) compared to non-teaching hospitals (0.03%), and 20 times higher in large bed hospitals (1.41%) compared to small bed-size hospitals (0.07%). CHF patients that received LVAD had a significantly longer LOS (34.6 days vs 9.8 days) and higher inpatient treatment costs ($802,118 vs. $86,302) compared to non-LVAD group. Conclusion The inpatient utilization of LVAD was in CHF patients is higher in males, blacks and private health insurance beneficiaries. In terms of hospital characteristics, the utilization of LVAD for CHF management was higher in large bed sized, and public type and teaching hospitals compared to their counterparts. This data will allow us to devise strategies to improve LVAD utilization and increase its outreach for heart failure patients, especially those on the transplant waiting list. Despite its effectiveness, aggressive usage of LVAD is restricted due to cost-effectiveness and lack of technical confidence among medical professional due to complications.

Cost-effectiveness of implantable ventricular assist devices in older children with stable, inotrope-dependent dilated cardiomyopathy

BACKGROUND

In a stable, inotrope-dependent pediatric patient with dilated cardiomyopathy, we evaluated the cost-effectiveness of continuous-flow VAD implantation compared to a watchful waiting approach using chronic inotropic therapy.

METHODS

We used a state-transition model to estimate the costs and outcomes of 14-year-old (INTERMACS profile 3) patients receiving either VAD or watchful waiting. We measured benefits in terms of lifetime QALYs gained. Model inputs were taken from the literature. We calculated the ICER, or the cost per additional QALY gained, of VADs and performed multiple sensitivity analyses to test how our assumptions influenced the results.

RESULTS

Compared to watchful waiting, VADs produce 0.97 more QALYs for an additional $156 639, leading to an ICER of $162 123 per QALY gained from a healthcare perspective. VADs have 17% chance of being cost-effective given a cost-effectiveness threshold of $100 000 per QALY gained. Sensitivity analyses suggest that VADs can be cost-effective if the costs of implantation decrease or if hospitalization costs or mortality among watchful waiting patients is higher.

CONCLUSIONS

As a bridge to transplant, VADs provide a health benefit to children who develop stable, inotrope-dependent heart failure, but immediate implantation is not yet a cost-effective strategy compared to watchful waiting based on commonly used cost-effectiveness thresholds. Early VAD support can be cost-effective in sicker patients and if device implantation is cheaper. In complex conditions such as pediatric heart failure, cost-effectiveness should be just one of many factors that inform clinical decision-making.

Novel Acoustic Biomarker of Quality of Life in Left Ventricular Assist Device Recipients

Background Although technological advances to pump design have improved survival, left ventricular assist device (LVAD) recipients experience variable improvements in quality of life. Methods for optimizing LVAD support to improve quality of life are needed. We investigated whether acoustic signatures obtained from digital stethoscopes can predict patient-centered outcomes in LVAD recipients. Methods and Results We followed precordial sounds over 6 months in 24 LVAD recipients (8 HeartWare HVAD™, 16 HeartMate 3 [HM3]). Subjects recorded their precordial sounds with a digital stethoscope and completed a Kansas City Cardiomyopathy Questionnaire weekly. We developed a novel algorithm to filter LVAD sounds from recordings. Unsupervised clustering of LVAD-mitigated sounds revealed distinct groups of acoustic features. Of 16 HM3 recipients, 6 (38%) had a unique acoustic feature that we have termed the pulse synchronized sound based on its temporal association with the artificial pulse of the HM3. HM3 recipients with the pulse synchronized sound had significantly better Kansas City Cardiomyopathy Questionnaire scores at baseline (median, 89.1 [interquartile range, 86.2-90.4] versus 66.1 [interquartile range, 31.1-73.7]; P=0.03) and over the 6-month study period (marginal mean, 77.6 [95% CI, 66.3-88.9] versus 59.9 [95% CI, 47.9-70.0]; P<0.001). Mechanistically, the pulse synchronized sound shares acoustic features with patient-derived intrinsic sounds. Finally, we developed a machine learning algorithm to automatically detect the pulse synchronized sound within precordial sounds (area under the curve, 0.95, leave-one-subject-out cross-validation). Conclusions We have identified a novel acoustic biomarker associated with better quality of life in HM3 LVAD recipients, which may provide a method for assaying optimized LVAD support.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Resource utilization in children with paracorporeal continuous-flow ventricular assist devices

BACKGROUND

Paracorporeal continuous-flow ventricular assist devices (PCF VAD) are increasingly used in pediatrics, yet PCF VAD resource utilization has not been reported to date.

METHODS

Pediatric Interagency Registry for Mechanically Assisted Circulatory Support (PediMACS), a national registry of VADs in children, and Pediatric Health Information System (PHIS), an administrative database of children's hospitals, were merged to assess VAD implants from 19 centers between 2012 and 2016. Resource utilization, including hospital and intensive care unit length of stay (LOS), and costs are analyzed for PCF VAD, durable VAD (DVAD), and combined PCF-DVAD support.

RESULTS

Of 177 children (20% PCF VAD, 14% PCF-DVAD, 66% DVAD), those with PCF VAD or PCF-DVAD are younger (median age 4 [IQR 0-10] years and 3 [IQR 0-9] years, respectively) and more often have congenital heart disease (44%; 28%, respectively) compared to DVAD (11 [IQR 3-17] years; 14% CHD); p < 0.01 for both. Median post-VAD LOS is prolonged ranging from 43 (IQR 15-82) days in PCF VAD to 72 (IQR 55-107) days in PCF-DVAD, with significant hospitalization costs (PCF VAD $450,000 [IQR $210,000-$780,000]; PCF-DVAD $770,000 [IQR $510,000-$1,000,000]). After adjusting for patient-level factors, greater post-VAD hospital costs are associated with LOS, ECMO pre-VAD, greater chronic complex conditions, and major adverse events (p < 0.05 for all). VAD strategy and underlying cardiac disease are not associated with LOS or overall costs, although PCF VAD is associated with higher daily-level costs driven by increased pharmacy, laboratory, imaging, and clinical services costs.

CONCLUSION

Pediatric PCF VAD resource utilization is staggeringly high with costs primarily driven by pre-implantation patient illness, hospital LOS, and clinical care costs.

An Increasing Burden of Disease: Emergency Department Visits Among Patients With Ventricular Assist Devices From 2010 to 2017

Background With a growing population of patients supported by ventricular assist devices (VADs) and the improvement in survival of this patient population, understanding the healthcare system burden is critical to improving outcomes. Thus, we sought to examine national estimates of VAD-related emergency department (ED) visits and characterize their demographic, clinical, and outcomes profile. Additionally, we tested the hypotheses that resource use increased and mortality improved over time. Methods and Results This retrospective database analysis uses encounter-level data from the 2010 to 2017 Nationwide Emergency Department Sample. The primary outcome was mortality. From 2010 to 2017, >880 million ED visits were evaluated, with 44 042 VAD-related ED visits identified. The annual mean visits were 5505 (SD 4258), but increased 16-fold from 2010 to 2017 (824 versus 13 155). VAD-related ED visits frequently resulted in admission (72%) and/or death (3.0%). Median inflation-adjusted charges were $25 679 (interquartile range, $7450, $63 119) per encounter. The most common primary diagnoses were cardiac (22%), and almost 30% of encounters were because of bleeding, stroke, or device complications. From 2010 to 2017, admission and mortality decreased from 82% to 71% and 3.4% to 2.4%, respectively (P for trends <0.001, both). Conclusions We present the first study using national-level data to characterize the growing ED resource use and financial burden of patients supported by VAD. During the past decade, admission and mortality rates decreased but remain substantial; in 2017 ≈1 in every 40 VAD ED encounters resulted in death, making it critical that clinical decision-making be optimized for patients with VAD to maximize good outcomes.

Complete sternal-sparing left ventricular assist device implantation is associated with improved postoperative mobility

Left ventricular assist device (LVAD) implantation via a complete sternal-sparing (CSS) technique is gaining interest due to several potential benefits. We hypothesized that the CSS approach for HeartMate 3 (HM3) LVAD implantation improves postoperative mobility and physical independence compared to full sternotomy (FS). We retrospectively reviewed patients who were implanted with a commercial HM3 at our institution from September 2017 to August 2018. The Activity Measure for Post-Acute Care short forms and Functional Independence Measure scores were used to assess the patient's physical limitations postoperatively. A total of 43 patients were included in the study: 27 (63%) CSS patients and 16 (37%) FS patients. At postoperative day 3, the CSS cohort demonstrated improved mobility based on Activity Measure for Post-Acute Care scores compared to the FS group; 40% of the CSS cohort versus 67% of the FS cohort remained 100% impaired. The CSS cohort also demonstrated greater postoperative independence in the Functional Independence Measure sit-to-stand metric with 78% of the CSS cohort achieving modified or complete independence by postoperative day 15 compared to only 21% of the FS patients. These early data suggest that the CSS approach for HM3 LVAD implantation improves postoperative mobility and functional independence compared to FS.

Cost-effectiveness of using hepatitis C viremic hearts for transplantation into HCV-negative recipients

Outcomes following hepatitis C virus (HCV)-viremic heart transplantation into HCV-negative recipients with HCV treatment are good. We assessed cost-effectiveness between cohorts of transplant recipients willing and unwilling to receive HCV-viremic hearts. Markov model simulated long-term outcomes among HCV-negative patients on the transplant waitlist. We compared costs (2018 USD) and health outcomes (quality-adjusted life-years, QALYs) between cohorts willing to accept any heart and those willing to accept only HCV-negative hearts. We assumed 4.9% HCV-viremic donor prevalence. Patients receiving HCV-viremic hearts were treated, assuming $39 600/treatment with 95% cure. Incremental cost-effectiveness ratios (ICERs) were compared to a $100 000/QALY gained willingness-to-pay threshold. Sensitivity analyses included stratification by blood type or region and potential negative consequences of receipt of HCV-viremic hearts. Compared to accepting only HCV-negative hearts, accepting any heart gained 0.14 life-years and 0.11 QALYs, while increasing costs by $9418/patient. Accepting any heart was cost effective (ICER $85 602/QALY gained). Results were robust to all transplant regions and blood types, except type AB. Accepting any heart remained cost effective provided posttransplant mortality and costs among those receiving HCV-viremic hearts were not >7% higher compared to HCV-negative hearts. Willingness to accept HCV-viremic hearts for transplantation into HCV-negative recipients is cost effective and improves clinical outcomes.

Cost-Effectiveness of a Small Intrapericardial Centrifugal Left Ventricular Assist Device

Supplemental Digital Content is available in the text.

There is limited data on the cost-effectiveness of continuous-flow left ventricular assist devices (LVAD) in the United States particularly for the bridge-to-transplant indication. Our objective is to study the cost-effectiveness of a small intrapericardial centrifugal LVAD compared with medical management (MM) and subsequent heart transplantation using the respective clinical trial data. We developed a Markov economic framework. Clinical inputs for the LVAD arm were based on prospective trials employing the HeartWare centrifugal-flow ventricular assist device system. To better assess survival in the MM arm, and in the absence of contemporary trials randomizing patients to LVAD and MM, estimates from the Seattle Heart Failure Model were used. Costs inputs were calculated based on Medicare claim analyses and when appropriate prior published literature. Time horizon was lifetime. Costs and benefits were appropriately discounted at 3% per year. The deterministic cost-effectiveness analyses resulted in $69,768 per Quality Adjusted Life Year and $56,538 per Life Year for the bridge-to-transplant indication and $102,587 per Quality Adjusted Life Year and $87,327 per Life Year for destination therapy. These outcomes signify a substantial improvement compared with prior studies and re-open the discussion around the cost-effectiveness of LVADs.

Clinical implications of differences between real world and clinical trial usage of left ventricular assist devices for end stage heart failure

Importance

Patient outcomes in heart failure clinical trials are generally better than those observed in real-world settings. This may be related to stricter inclusion and exclusion criteria in clinical trials.

Objective

We study sought to characterize the clinical implications of differences between patients in clinical trials and those in a real-world registry of patients receiving left ventricular assist devices (LVADs).

Design, setting, and participants

This retrospective cohort study included all patients in INTERMACS (the Interagency Registry for Mechanically Assisted Circulatory Support) who were implanted with an axial flow LVAD from 2010 to 2015 to allow for equivalent comparisons.

Main outcomes and measures

Differences in patient characteristics and 2-year rates of adverse outcomes with those reported in the ENDURANCE and MOMENTUM 3 clinical trials. Survival analyses were used to assess the relationships between prespecified patient factors and clinical outcomes.

Results

Of the 10,937 LVAD recipients identified in INTERMACS between 2010–2015, 44% met at least 1 clinical trial exclusion criterion. The 2-year incidence of stroke and death amongst LVAD recipients in INTERMACS and the landmark clinical trials differed significantly (P<0.04, both). Nevertheless, patients who would have been excluded from the clinical trials did not have dramatically different 2-year mortality outcomes in INTERMACS [2y survival estimate: 66.4%, 95% CI (64.9–67.9%) versus 71.9%, 95% CI (70.6–73.1%)]. Clinical interventions driving a significantly increased risk of death were relatively rare (<5% of implants) and included mechanical ventilation, ECMO, severe thrombocytopenia, and dialysis.

Conclusions and relevance

Most exclusion criteria used in LVAD clinical trials did not afford a substantially greater risk to patients in the real-world setting. In the relatively infrequent cases of end stage renal disease, thrombocytopenia, respiratory failure, and need for ECMO, the risks and benefits of LVAD therapy need careful weighting and further study.

Gallium-67 Single-Photon Emission Computed Tomography Affects Management of Infections of Left Ventricular Assist Devices

Our institution employs gallium-67 single-photon emission computed tomography low-dose CT (Ga-SPECT-CT) to determine the presence and extent of left ventricular assist device (LVAD) infections. We present a retrospective single-center study of 41 LVAD recipients who underwent Ga-SPECT-CT from January 2011 to June 2018 to determine whether Ga-SPECT-CT led to changes in antimicrobial therapy, LVAD revision or exchange, or application for 1A exception. The average age was 56.6 years, predominantly male (80.5%) and diabetic (68.3%), divided between ischemic (48.8%) and nonischemic (51.2%) cardiomyopathy. The majority had HeartMate II devices (82.9%). Device-related infections were classified as possible (12.2%), probable (36.6%), proven (36.6%), or rejected (14.6%). Sensitivity was 68.6% and specificity was 100%. Most VAD-specific infections were percutaneous deep driveline infections (DRIs) (34.1%), and VAD-related infections were primarily bloodstream infections (31.7%). Staphylococcus aureus was the major pathogen isolated. Gallium-67 single-photon emission computed tomography low-dose CT resulted in changes in management in more than half (53.7%) of patients: starting (24.4%) or stopping (17.1%) antimicrobial therapy, LVAD revision (22.0%) or exchange (12.2%), and the application for 1A exception for transplant listing (17.1%). We conclude that Ga-SPECT-CT is an effective modality for determining the presence and extent of LVAD DRIs, and contributed to a change in management in more than half of cases.

National Landscape of Hospitalizations in Patients with Left Ventricular Assist Device. Insights from the National Readmission Database 2010-2015

The number of patients with left ventricular assist devices (LVAD) has increased over the years and it is important to identify the etiologies for hospital admission, as well as the costs, length of stay and in-hospital complications in this patient group. Using the National Readmission Database from 2010 to 2015, we identified patients with a history of LVAD placement using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code V43.21. We aimed to identify the etiologies for hospital admission, patient characteristics, and in-hospital outcomes. We identified a total of 15,996 patients with an LVAD, the mean age was 58 years and 76% were males. The most common cause of hospital readmission after LVAD was heart failure (HF, 13%), followed by gastrointestinal (GI) bleed (11.8%), device complication (11.5%), and ventricular tachycardia/fibrillation (4.2%). The median length of stay was 6 days (3-11 days) and the median hospital costs was $12,723 USD. The in-hospital mortality was 3.9%, blood transfusion was required in 26.8% of patients, 20.5% had acute kidney injury, 2.8% required hemodialysis, and 6.2% of patients underwent heart transplantation. Interestingly, the most common cause of readmission was the same as the diagnosis for the preceding admission. One in every four LVAD patients experiences a readmission within 30 days of a prior admission, most commonly due to HF and GI bleeding. Interventions to reduce HF readmissions, such as speed optimization, may be one means of improving LVAD outcomes and resource utilization.

Clinical Outcomes of Early Extubation Strategy in Patients Undergoing Extracorporeal Membrane Oxygenation as a Bridge to Heart Transplantation

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) might be considered a bridge therapy in patients who are expected to have short waiting times for heart transplantation. We investigated the clinical outcomes of patients who underwent VA-ECMO as a bridge to heart transplantation and whether the deployment of an early extubation ECMO strategy is beneficial.

METHODS

Between November 2006 and December 2018, we studied 102 patients who received VA-ECMO as a bridge to heart transplantation. We classified these patients into an early extubation ECMO group (n = 24) and a deferred extubation ECMO group (n = 78) based on the length of the intubated period on VA-ECMO (≤ 48 hours or > 48 hours). The primary outcome was in-hospital mortality.

RESULTS

The median duration of early extubation VA-ECMO was 10.0 (4.3-17.3) days. The most common cause for patients to be put on ECMO was dilated cardiomyopathy (65.7%) followed by ischemic cardiomyopathy (11.8%). In-hospital mortality rates for the deferred extubation and early extubation groups, respectively, were 24.4% and 8.3% (P = 0.147). During the study period, in the deferred extubation group, 60 (76.9%) underwent transplantation, while 22 (91.7%) underwent transplantation in the early extubation group. Delirium occurred in 83.3% and 33.3% of patients from the deferred extubation and early extubation groups (P < 0.001) and microbiologically confirmed infection was identified in 64.1% and 41.7% of patients from the two groups (P = 0.051), respectively.

CONCLUSION

VA-ECMO as a bridge therapy seems to be feasible for deployment in patients with a short waiting time for heart transplantation. Deployment of the early extubation ECMO strategy was associated with reductions in delirium and infection in this population.

Deep Natural Language Processing to Identify Symptom Documentation in Clinical Notes for Patients With Heart Failure Undergoing Cardiac Resynchronization Therapy

CONTEXT

Clinicians lack reliable methods to predict which patients with congestive heart failure (CHF) will benefit from cardiac resynchronization therapy (CRT). Symptom burden may help to predict response, but this information is buried in free-text clinical notes. Natural language processing (NLP) may identify symptoms recorded in the electronic health record and thereby enable this information to inform clinical decisions about the appropriateness of CRT.

OBJECTIVES

To develop, train, and test a deep NLP model that identifies documented symptoms in patients with CHF receiving CRT.

METHODS

We identified a random sample of clinical notes from a cohort of patients with CHF who later received CRT. Investigators labeled documented symptoms as present, absent, and context dependent (pathologic depending on the clinical situation). The algorithm was trained on 80% and fine-tuned parameters on 10% of the notes. We tested the model on the remaining 10%. We compared the model's performance to investigators' annotations using accuracy, precision (positive predictive value), recall (sensitivity), and F1 score (a combined measure of precision and recall).

RESULTS

Investigators annotated 154 notes (352,157 words) and identified 1340 present, 1300 absent, and 221 context-dependent symptoms. In the test set of 15 notes (35,467 words), the model's accuracy was 99.4% and recall was 66.8%. Precision was 77.6%, and overall F1 score was 71.8. F1 scores for present (70.8) and absent (74.7) symptoms were higher than that for context-dependent symptoms (48.3).

CONCLUSION

A deep NLP algorithm can be trained to capture symptoms in patients with CHF who received CRT with promising precision and recall.

Left ventricular assist devices in the elderly: Marching forward with cautions

Congestive heart failure is highly prevalent in the elderly population and left ventricular assist device (LVAD) has been increasingly used in this population. LVAD therapy is more costly than medical treatment but it increases the survival and quality of life of the elderly patients with low disease acuity. Therefore careful selection of candidates and implementation of LVAD therapy earlier in the course of the disease is crucial to improve outcomes. With the technical advances and improvement in clinical management, the financial burden of LVAD therapy in the elderly will become less, making this therapy more economically feasible.

Patterns of emergency department utilization for LVAD patients compared with non-LVAD patients

Background

Left ventricular assist device (LVAD) patients are vulnerable to over-utilization of resources.

Methods and results

We explored the pattern of emergency department (ED) presentations of LVAD patients and their costs compared with non-LVAD heart failure patients. ED visits between 7/2008 and 7/2017 were reviewed to identify 145 LVAD patients, and 435 patients with known heart failure were selected using propensity score matching for age and sex. ED evaluation metrics, hospitalization cost, and length of stay (LOS) were analyzed. Although the most common ED presentations and their frequency differed between groups, few were LVAD specific. LVAD patients were more likely to have taken personal vehicles or be flown to the ED. They had similar times to triage, rooming, and physician evaluation compared with non-LVAD patients. However, LVAD patients were noted to have a shorter time from physician assessment to disposition (109.8 min vs. 177.0 min, p < 0.001) and, overall, LVAD patients had shorter ED LOS (6.33 vs. 9.82 hrs, p = 0.0001). For patients admitted, no significant difference was found between groups in hospital LOS (6.67 vs 6.58 days, p = 0.928) or total cost ($28,766 vs $21,524, p = 0.087).

Conclusion

Shorter disposition times without increases in LOS or costs may identify a created healthcare disparity among LVAD patients.

Circulating non-coding RNAs in biomarker-guided cardiovascular therapy: a novel tool for personalized medicine?

Current clinical guidelines emphasize the unmet need for technological innovations to guide physician decision-making and to transit from conventional care to personalized cardiovascular medicine. Biomarker-guided cardiovascular therapy represents an interesting approach to inform tailored treatment selection and monitor ongoing efficacy. However, results from previous publications cast some doubts about the clinical applicability of biomarkers to direct individualized treatment. In recent years, the non-coding human transcriptome has emerged as a new opportunity for the development of novel therapeutic strategies and biomarker discovery. Non-coding RNA (ncRNA) signatures may provide an accurate molecular fingerprint of patient phenotypes and capture levels of information that could complement traditional markers and established clinical variables. Importantly, ncRNAs have been identified in body fluids and their concentrations change with physiology and pathology, thus representing promising non-invasive biomarkers. Previous publications highlight the translational applicability of circulating ncRNAs for diagnosis and prognostic stratification within cardiology. Numerous independent studies have also evaluated the potential of the circulating non-coding transcriptome to predict and monitor response to cardiovascular treatment. However, this field has not been reviewed in detail. Here, we discuss the state-of-the-art research into circulating ncRNAs, specifically microRNAs and long non-coding RNAs, to support clinical decision-making in cardiovascular therapy. Furthermore, we summarize current methodological and conceptual limitations and propose future steps for their incorporation into personalized cardiology. Despite the lack of robust population-based studies and technical barriers, circulating ncRNAs emerge as a promising tool for biomarker-guided therapy.