Dying With a Left Ventricular Assist Device as Destination Therapy

ENABLE-LVAD: Development and Implementation of a Novel Training Program for Clinicians Supporting Family Caregivers of Patients With a Left Ventricular Assist Device

BACKGROUND

Despite significant family caregiver (FCG) burnout, there are currently no tested interventions to support the FCG role after left ventricular assist device (LVAD) implantation or formalized training for clinicians to support FCGs.

OBJECTIVE

We adapted the existing ENABLE (Educate, Nurture, Advise Before Life Ends) intervention to LVAD clinicians and FCGs and assessed clinical implementation and dissemination.

METHODS

ENABLE-LVAD is an interactive, self-paced clinician training coupled with FCG-facing guidebooks and resources. Implementation and dissemination were evaluated by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework.

RESULTS

As of May 2023, 187 clinicians registered for the training, and 41 completed all modules (22.0% completion rate). Of those who completed the training and responded to a 6-month survey, one-third (n = 10, 33.3%) used ENABLE-LVAD with FCGs, and 100% of those planned to continue using it. The primary barrier to completing the training was time.

CONCLUSIONS

The ENABLE-LVAD clinician training was successfully disseminated and implemented as a useful resource to support LVAD FCGs.

The experiences among bereaved family members after a left ventricular assist device (LVAD) deactivation

BACKGROUND

The use of left ventricular assist devices (LVADs) is increasing with an estimated 2500 devices implanted each year. When burdens of the LVAD outweigh benefits, most individuals with LVADs will undergo deactivation in the hospital setting. While the decision to deactivate an LVAD is considered an ethical practice, little is known about the experience and needs of bereaved family members.

OBJECTIVE

To investigate the experiences of bereaved family members of patients who died following LVAD deactivation.

METHODS

In this qualitative study, 11 family members of patients who underwent LVAD deactivation were interviewed. The semi-structured interviews were conducted until data saturation was reached and relevant themes emerged.

RESULTS

This qualitative study was conducted to understand the experience of family members before, during and after the patient underwent LVAD deactivation, including their perceptions of engagement with the healthcare team. Analysis revealed six overarching themes from the experience, including 1) hope for survival, 2) communication, 3) spirituality and faith, 4) absence of physical suffering, 5) positive relationships with staff, 6) post-death care needs.

CONCLUSION

Bereaved family members of patients undergoing LVAD deactivation have unique lived experiences and concerns. This study highlights the importance of effective communication not only near end-of-life but throughout the LVAD experience. While the positive relationships with staff and the absence of physical suffering were strengths identified by bereaved caregivers, there is an opportunity for improvement, particularly during the decision-making and post-death periods.

Integration of palliative care across the spectrum of heart failure care and therapies: considerations, contemporary data, and challenges

PURPOSE OF REVIEW

Heart failure (HF) is characterized by significant symptoms, compromised quality of life, frequent hospital admissions, and high mortality, and is therefore well suited to palliative care (PC) intervention. This review elaborates the current PC needs of patients with HF across the spectrum of disease, including patients who undergo advanced HF surgical therapies, and reviews the current data and future directions for PC integration in HF care.

RECENT FINDINGS

Patients with chronic HF, as well as those who are being evaluated for or who have undergone advanced HF surgical therapies such as left ventricular assist device or heart transplantation, have a number of PC needs, including decision-making, symptoms and quality of life, caregiver support, and end-of-life care. Available data primarily supports the use of PC interventions in chronic HF to improve quality of life and symptoms. PC skills and teams may also help address preparedness planning, adverse events, and psychosocial barriers in patients who have had HF surgeries, but more data are needed to determine association with outcomes.

SUMMARY

Patients with HF have tremendous PC needs across the spectrum of disease. Despite this, more data are needed to determine the optimal timing and structure of PC interventions in patients with chronic HF, left ventricular assist device, and heart transplantation. Future steps must be taken in clinical, research, and policy domains in order to optimize care.

The Complex Ethical and Moral Experience of Left Ventricular Assist Device Deactivation

The left ventricular assist device (LVAD) is a fully implantable cardiac replacement device that can complicate the process of dying. We present a case of a patient who attempted to deactivate the LVAD without the support of his medical team. This action was understood as a "suicide attempt" though when the patient was later felt to be dying, LVAD deactivation proceeded without reference to psychiatric illness. To understand this case, we discuss the ethics of LVAD deactivation in the dying process. We then explore the experience of clinicians and the public encountering this unique technology across clinical contexts. We herein present a novel and possibly controversial analysis of the moral complexities of LVAD deactivation and suggest that clinicians be transparent about these complexities with patients and families.

Left Ventricular Assist Device and the Current State of the Art: HeartMate 3 at 5 Years

Left ventricular assist devices (LVADs) or cardiac transplantation are the two prevailing methods of treating patients with end-stage heart failure. The availability of donor hearts is insufficient to meet the needs of patients with advanced heart failure. LVADs offer a potential alternative to transplantation for those patients who cannot wait or are otherwise unsuited for cardiac transplantation. The field has made tremendous progress in the past 20 years. In this review, the current state of the art is summarized with respect to current generation LVADs.

Post-infarct evolution of ventricular and myocardial function

Adverse ventricular remodeling following acute myocardial infarction (MI) may induce ventricular dilation, fibrosis, and loss of global contractile function, possibly resulting in heart failure (HF). Understanding the relation between the time-dependent changes in material properties of the myocardium and the contractile function of the heart may further our understanding of the development of HF post-MI and guide the development of novel therapies. A finite element model of cardiac mechanics was used to model MI in a thick-walled truncated ellipsoidal geometry. Infarct core and border zone comprised 9.6 and 8.1% of the LV wall volume, respectively. Acute MI was modeled by inhibiting active stress generation. Chronic MI was modeled by the additional effect of infarct material stiffening, wall thinning and fiber reorientation. In acute MI, stroke work decreased by 25%. In the infarct core, fiber stress was reduced but fiber strain was increased, depending on the degree of infarct stiffening. Fiber work density was equal to zero. Healthy tissue adjacent to the infarct showed decreased work density depending on the degree of infarct stiffness and the orientation of the myofibers with respect to the infarct region. Thinning of the wall partially restored this loss in work density while the effects of fiber reorientation were minimal. We found that the relative loss in pump function in the infarcted heart exceeds the relative loss in healthy myocardial tissue due to impaired mechanical function in healthy tissue adjacent to the infarct. Infarct stiffening, wall thinning and fiber reorientation did not affect pump function but did affect the distribution of work density in tissue adjacent to the infarct.

Deactivation of Left Ventricular Assist Devices at the End of Life: Narrative Review and Ethical Framework

Left ventricular assist devices (LVADs) have become an increasingly common advanced therapy in patients with severe symptomatic heart failure. Their unique nature in prolonging life through incorporation into the circulatory system raises ethical questions regarding patient identity and values, device ontology, and treatment categorization; approaching requests for LVAD deactivation requires consideration of these factors, among others. To that end, clinicians would benefit from a deeper understanding of: 1) the history and nature of LVADs; 2) the wider context of device deactivation and associated ethical considerations; and 3) an introductory framework incorporating best practices in requests for LVAD deactivation (specifically in controversial situations without obvious medical or device-related complications). In such decisions, heart failure teams can safeguard patient preferences without compromising ethical practice through more explicit advance care planning before LVAD implantation, early integration of hospice and palliative medicine specialists (maintained throughout the disease process), and further research interrogating behaviors and attitudes related to LVAD deactivation.

Clinical Protocol for Left Ventricular Assist Device Deactivation at End of Life

As patients live longer with left ventricular assist device (LVAD) support, many will either suffer an acute event or develop a gradual, progressive disease that results in a terminal prognosis. At the end-of-life, patients, and more often, their families, will be faced with the decision to deactivate the LVAD to allow natural death. The process of LVAD deactivation carries some distinct features that distinguish it from withdrawal of other forms of life-sustaining medical technology: multidisciplinary collaboration is paramount; prognosis after deactivation is short, typically minutes-hours; and premedication doses of symptom-focused medications are typically higher than other situations involving withdrawal of life-sustaining medical technologies given the precipitous decline in cardiac output following LVAD deactivation. In this Case Discussion, we introduce the complexity of planned in-hospital LVAD deactivation through a clinical case, share our detailed institutional checklist and order set for LVAD deactivation, and broach multidisciplinary clinical protocol development processes.

Bariatric surgery and left ventricular assist device in patients with heart failure: A systematic review and meta-analysis

BACKGROUND

The role of metabolic and bariatric surgery (MBS), in synergy with left ventricular assist device (LVAD) implantation, in the scope of end-stage heart failure management for patients with severe obesity is not well elucidated.

METHODS

We conducted a meta-analysis using Cochrane, Embase, PubMed, and Scopus databases to include articles from their inception to November 2022.

RESULTS

A total of 271 patients who underwent MBS during or after the LVAD implantation were included from eleven separate studies. After surgery, 67.4% of patients were listed on the heart transplant waitlist with 32.5% undergoing a successful transplant. We reported a mean listing time of 13.8 months. Finally, the pooled postoperative complication rate, 30-day readmission rate, and one-year mortality rate were 47.6%, 23.6% and 10.2% respectively.

CONCLUSIONS

MBS and LVAD is a safe and effective approach to bridge patients with severe obesity and end-stage heart failure for definitive heart transplantation.

Deciding to Live (or Not) With a Left Ventricular Assist Device-a Thematic Analysis Exploring Factors Influencing the Decision-Making Process in Advanced Heart Failure Patients in Singapore

Background: It is often difficult for patients with advanced heart failure (HF) to decide whether to live with a left ventricular assist device (LVAD) or not. Little is known about their decisional needs prior to LVAD implantation and if these needs were met in the Asian cultural setting. Aims: We aimed to explore the influences, concerns, and needs surrounding the decision-making process of the LVAD implantation among multi-ethnic Asian patients with HF. Methods: Semi-structured interviews with HF patients and caregivers were conducted, based upon the grounded theory approach. Participants were purposively recruited from the inpatient and outpatient setting of the National Heart Centre Singapore. Results: A total of 31 patients and 11 caregivers participated. Mindsets that shaped decision-making ranged from "having no choice," "being reflective," "taking a gamble," and "fighting on." Instead of making a sole decision, many patients reported that decisions were shared with the family or medical team. Current LVAD patients who acted as patient ambassadors were also strong influences. Spiritual support was pivotal to decision-making for some participants. Goals influencing decision-making including protecting the family and life prolongation improving quality of life. Values held close included sanctity of life, trusting in a higher power, believing in pre-destination or karma, and preserving family harmony. Participants had concerns about cost, employment, and health outcomes. Conclusions: Asian LVAD patients and caregivers had culturally specific mindsets, goals, and values and concerns around decision-making. Our findings have implications for the design of interventions and supportive care models.

End-of-Life in Pediatric Patients Supported by Ventricular Assist Devices: A Network Database Cohort Study

OBJECTIVES

Most pediatric patients on ventricular assist device (VAD) survive to transplantation. Approximately 15% will die on VAD support, and the circumstances at the end-of-life are not well understood. We, therefore, sought to characterize patient location and invasive interventions used at the time of death.

DESIGN

Retrospective database study of a cohort meeting inclusion criteria.

SETTING

Thirty-six centers participating in the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Registry.

PATIENTS

Children who died on VAD therapy in the period March 2012 to September 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 117 of 721 patients (16%) who died on VAD, the median (interquartile range) age was 5 years (1-16 yr) at 43 days (17-91 d) postimplant. Initial goals of therapy were bridge to consideration for candidacy for transplantation in 60 of 117 (51%), bridge to transplantation in 44 of 117 (38%), bridge to recovery 11 of 117 (9%), or destination therapy (i.e., VAD as the endpoint) in two of 117 (2%). The most common cause of death was multiple organ failure in 35 of 117 (30%), followed by infection in 12 of 117 (10%). Eighty-five of 92 (92%) died with a functioning device in place. Most patients were receiving invasive interventions (mechanical ventilation, vasoactive infusions, etc.) at the end of life. Twelve patients (10%) died at home.

CONCLUSIONS

One-in-six pediatric VAD patients die while receiving device support, with death occurring soon after implant and usually from noncardiac causes. Aggressive interventions are common at the end-of-life. The ACTION Registry data should inform future practices to promote informed patient/family and clinician decision-making to hopefully reduce suffering at the end-of-life.

In-Hospital Left Ventricular Assist Devices Deactivation and Death Experience: A Single-Institution Retrospective Analysis

Best practices for left ventricular assist devices (LVADs) deactivation at end-of-life (EOL) have yet to be elucidated. We conducted a single-institution retrospective review of patients who died following LVAD deactivation between January 2017 and March 2020. Data were obtained from institutional databases and electronic health record and were analyzed using descriptive statistics. Fifty-eight patients (70% male, 70% African American, median age 62 years) were categorized by implant strategy: bridge therapy (BT, N = 22, 38%) or destination therapy (DT, N = 36, 62%). Clinical events leading to deactivation were categorized either acute ( e.g. , stroke [ N = 31, 53%]), gradual decline ( N = 12, 21%), or complications during index hospitalization ( N = 15, 26%). Implant strategy was not associated with clinical trajectory leading to EOL ( p = 0.67), hospital unit of death ( p = 0.13), or use of mechanical ventilation ( p = 0.69) or renal replacement therapy ( p = 0.81) during terminal hospitalization. Overall time from admission to code status change was mean 27.0 days (SD 30.3 days). Compared with BT patients, DT experienced earlier do-not-resuscitate (DNR) orders ( p ≤ 0.01) and shorter survival post-deactivation ( p ≤ 0.01). Deactivations after gradual decline tended to occur outside ICUs, compared with acute events or index implant-related complications ( p = 0.04). Implant strategy was not associated with differences in EOL experience except regarding timing of DNR order and survival post-deactivation.

End-of-Life Care for End-stage Heart Failure Patients

Although recent heart failure (HF) guidelines highlight integrative palliative care, including end-of-life (EOL), appropriate discussing EOL issues can be challenging due to possibility of unexpected deterioration throughout HF trajectory. Open communication and discussions with multidisciplinary team are important for setting patient and family expectations and establishing mutually agreed goals of care based firmly on the patient’s ‘human dignity’ and ‘right to self-determination.’ Especially when quality-of-life outweighs expanding quantity-of-life, transition to EOL care should be considered. Advanced care planning including resuscitation, device deactivation, site for last days, and bereavement support should focus on ensuring a good death, and be reviewed regularly.

Efforts to improve end-of-life (EOL) care have generally been focused on cancer patients, but high-quality EOL care is also important for patients with other serious medical illnesses including heart failure (HF). Recent HF guidelines offer more clinical considerations for palliative care including EOL care than ever before. Because HF patients can experience rapid, unexpected clinical deterioration or sudden death throughout the disease trajectory, choosing an appropriate time to discuss issues such as advance directives or hospice can be challenging in real clinical situations. Therefore, EOL issues should be discussed early. Conversations are important for understanding patient and family expectations and developing mutually agreed goals of care. In particular, high-quality communication with patient and family through a multidisciplinary team is necessary to define patient-centered goals of care and establish treatment based on goals. Control of symptoms such as dyspnea, pain, anxiety/depression, fatigue, nausea, anorexia, and altered mental status throughout the dying process is an important issue that is often overlooked. When quality-of-life outweighs expanding quantity-of-life, the transition to EOL care should be considered. Advanced care planning including resuscitation (i.e., do-not resuscitate order), device deactivation, site for last days and bereavement support for the family should focus on ensuring a good death and be reviewed regularly. It is essential to ensure that treatment for all HF patients incorporates discussions about the overall goals of care and individual patient preferences at both the EOL and sudden changes in health status. In this review, we focus on EOL care for end-stage HF patients.

Ethical and Legal Concerns Associated With Withdrawing Mechanical Circulatory Support: A U.S. Perspective

Hundreds of thousands of Americans have advanced heart failure and experience severe symptoms (e. g., dyspnea) with minimal exertion or at rest despite optimal management. Although heart transplant is an effective treatment for advanced heart failure, the demand for organs far exceeds the supply. Another option for these patients is mechanical circulatory support (MCS) provided by devices such as the ventricular assist device and total artificial heart. MCS alleviates symptoms, prolongs life, and provides a “bridge to transplant” or a decision regarding future management such as “destination therapy,” in which the patient receives lifelong MCS. However, a patient receiving MCS, or his/her surrogate decision-maker, may conclude ongoing MCS is burdensome and no longer consistent with the patient's healthcare-related values, goals, and preferences and, as a result, request withdrawal of MCS. Likewise, the patient's clinician and care team may conclude ongoing MCS is medically ineffective and recommend its withdrawal. These scenarios raise ethical and legal concerns. In the U.S., it is ethically and legally permissible to carry out an informed patient's or surrogate's request to withdraw any treatment including life-sustaining treatment (LST) if the intent is to remove a treatment perceived by the patient as burdensome and not to terminate intentionally the patient's life. Under these circumstances, death that follows withdrawal of the LST is due to the underlying disease and not a form of physician-assisted suicide or euthanasia. In this article, frequently encountered ethical and legal concerns regarding requests to withdraw MCS are reviewed: the ethical and legal permissibility of withholding or withdrawing LSTs from patients who no longer want such treatments; what to do if the clinician concludes ongoing LST will not result in achieving clinical goals (i.e., medically ineffective); responding to requests to withdraw LST; the features of patients who undergo withdrawal of MCS; the rationale for advance care planning in patients being considered for, or receiving, MCS; and other related topics. Notably, this article reflects a U.S. perspective.

Inpatient Specialist Palliative Care in Patients With Left Ventricular Assist Devices (LVAD): A Retrospective Case Series

Background

Repeat hospitalizations, complications, and psychosocial burdens are common in patients with left ventricular assist devices (LVAD). Specialist palliative care (sPC) involvement supports patients during decision-making until end-of-life. In the United States, guidelines recommend early specialist palliative care (esPC) involvement prior to implantation. Yet, data about sPC and esPC involvement in Europe are scarce.

Materials and Methods

This is a retrospective descriptive study of deceased LVAD patients who had received sPC during their LVAD-related admissions to two university hospitals in Duesseldorf, Germany and Basel, Switzerland from 2010 to 2021. The main objectives were to assess: To which extent have LVAD patients received sPC, how early is sPC involved? What are the characteristics of those, how did sPC take place and what are key challenges in end-of-life care?

Results

In total, 288 patients were implanted with a LVAD, including 31 who received sPC (11%). Twenty-two deceased LVAD patients (19 male) with sPC were included. Mean patient age at the time of implantation was 67 (range 49–79) years. Thirteen patients (59%) received LVAD as destination therapy, eight patients (36%) were implanted as bridge to transplantation (BTT), and one as an emergency LVAD after cardiogenic shock (5%). None of the eight BTT patients received a heart transplantation before dying. Most (n = 13) patients lived with their family and mean Eastern Cooperative Oncology Group (ECOG) performance status was three. Mean time between LVAD implantation and first sPC contact was 1.71 years, with a range of first sPC contact from 49 days prior to implantation to more than 6 years after. Two patients received esPC before implantation. In Duesseldorf, mean time between first sPC contact and in-hospital death was 10.2 (1–42) days. In Basel, patients died 16 (0.7–44) months after first sPC contact, only one died on the external sPC unit. Based on thorough examination of two case reports, we describe key challenges of sPC in LVAD patients including the necessity for sPC expertise, ethical and communicative issues as well as the available resources in this setting.

Conclusion

Despite unequivocal recommendations for sPC in LVAD patients, the integration of sPC for these patients is yet not well established.

Time Spent Engaging in Health Care Among Patients With Left Ventricular Assist Devices

OBJECTIVES

This study aims to examine a novel patient-centered metric of time spent engaging in left ventricular assist device (LVAD)-related clinical care outside the home.

BACKGROUND

Although LVAD implantation can improve survival and functional capacity in patients with advanced heart failure, this may occur at the expense of significant time spent engaging in LVAD-related health care activities.

METHODS

The authors retrospectively assessed consecutive patients at a single center who received a continuous-flow LVAD between May 9, 2008, and December 31, 2019, and queried health care encounters after implantation, including all inpatient encounters and LVAD-related ambulatory encounters. Patient-level time metrics were determined, including the total number of days with any health care encounter, and the total estimated time spent receiving care. The primary outcome was the proportion (%) of days alive with an LVAD spent engaged in at least 1 health care encounter. The secondary outcome was the proportion (%) of total time alive with an LVAD spent receiving care.

RESULTS

Among 373 patients, the median number of days alive with LVAD was 390 (IQR: 158-840 days). Patients had a median number of 88 (IQR: 45-161) days with ≥1 health care encounter, accounting for 23.2% (IQR: 16.3%-32.4%) of their days alive with an LVAD. A median 6.0% (IQR: 2.1%-14.1%) and 15.0% (IQR: 10.7%-20.0%) of total days alive were spent in inpatient and ambulatory encounters, respectively. Patients spent a median of 592 (IQR: 197-1,257) hours receiving care, accounting for 5.6% (IQR: 2.2%-12.7%) of their total time alive with an LVAD.

CONCLUSIONS

LVAD patients spent more than 1 of every 5 days engaging in health care. Our findings may inform strategies to improve efficiency of postdischarge care delivery and expectations for post-treatment care.

The Fountain of Youth Will Not Last Forever: End of Life in Patients Receiving Mechanical Circulatory Support

Health care providers face a unique set of decision-making, assessment, and equipment challenges at the end of life of patients supported with a left ventricular assist device. The aim for this article is to assist the multidisciplinary team in caring for patients with a left ventricular assist device in all phases of end-of-life care. This review includes common causes of death for patients with a left ventricular assist device, assessment at end of life, physiological and palliative care considerations, withdrawal of left ventricular assist device support, and equipment considerations.

HFA of the ESC position paper on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider Part 3: at the hospital and discharge

The growing population of left ventricular assist device (LVAD)‐supported patients increases the probability of an LVAD‐ supported patient hospitalized in the internal or surgical wards with certain expected device related, and patient‐device interaction complication as well as with any other comorbidities requiring hospitalization. In this third part of the trilogy on the management of LVAD‐supported patients for the non‐LVAD specialist healthcare provider, definitions and structured approach to the hospitalized LVAD‐supported patient are presented including blood pressure assessment, medical therapy of the LVAD supported patient, and challenges related to anaesthesia and non‐cardiac surgical interventions. Finally, important aspects to consider when discharging an LVAD patient home and palliative and end‐of‐life approaches are described.

Compassionate Deactivation of Pediatric Ventricular Assist Devices: A Review of 14 Cases

CONTEXT

Compassionate deactivation (CD) of ventricular assist device (VAD) support is a recognized option for children when the burden of therapy outweighs the benefits.

OBJECTIVES

To describe the prevalence, indications, and outcomes of CD of children supported by VADs at the end of life.

METHODS

Review of cases of CD at our institution between 2011 and 2020. To distinguish CD from other situations where VAD support is discontinued, patients were excluded from the study if they died during resuscitation (including extracorporeal membrane oxygenation), experienced brain or circulatory death prior to deactivation, or experienced a non-survivable brain injury likely to result in imminent death regardless of VAD status.

RESULTS

Of 24 deaths on VAD, 14 (58%) were CD. Median age was 5.7 (interquartile range (IQR) 0.6, 11.6) years; 6 (43%) had congenital heart disease; 4 (29%) were on a device that can be used outside of the hospital. CD occurred after 40 (IQR: 26, 75) days of support; none while active transplant candidates. CD discussions were initiated by the caregiver in 6 (43%) cases, with the remainder initiated by a medical provider. Reasons for CD were multifactorial, including end-organ injury, infection, and stroke. CD occurred with endotracheal extubation and/or discontinuation of inotropes in 12 (86%) cases, and death occurred within 10 (IQR: 4, 23) minutes of CD.

CONCLUSION

CD is the mode of death in more than half of our VAD non-survivors and is pursued for reasons primarily related to noncardiac events. Caregivers and providers both initiate CD discussions. Ventilatory and inotropic support is often withdrawn at time of CD with ensuing death.

Perceptions of Bereaved Caregivers and Clinicians About End-of-Life Care for Patients With Destination Therapy Left Ventricular Assist Devices

Background Patients with left ventricular assist devices (LVADs) implanted as destination therapy may receive suboptimal preparation for and care at the end of life, but there is limited understanding of the reasons for these shortcomings. Exploring perceptions of individuals (caregivers and clinicians) who are closely involved in the end-of-life experience with patients with destination therapy LVADs can help identify key opportunities for improving care. Methods and Results We conducted semistructured qualitative interviews with 7 bereaved caregivers of patients with destination therapy LVADs and 10 interdisciplinary LVAD clinicians. Interviews explored perceptions of preparing for end of life, communicating about end of life, and providing and receiving end-of-life care, and were analyzed using a 2-step team-based inductive approach to coding and analysis. Six themes pertaining to end-of-life experiences were derived: (1) timing end-of-life discussions in the setting of unpredictable illness trajectories, (2) prioritizing end-of-life preparation and decision-making, (3) communicating uncertainty while providing support and hope, (4) lack of consensus on responsibility for end-of-life discussions, (5) perception of the LVAD team as invincible, and (6) divergent perceptions of LVAD withdrawal. Conclusions This study revealed 6 unique aspects of end-of-life care for patients with destination therapy LVADs as reported by clinicians and caregivers. Themes coalesced around communication, team-based care, and challenges unique to patients with LVADs at end of life. Programmatic changes may address some aspects, including training clinicians in LVAD-specific communication skills. Other aspects, such as standardizing the role of the palliative care team and developing practical interventions that enable timely advance care planning during LVAD care, will require multifaceted interventions.

Advances in Cardiopulmonary Life-Support Change the Meaning of What It Means to be Resuscitated

As options for advanced cardiopulmonary support proliferate, the use of mechanical circulatory support, such as left ventricular assist device as destination therapy (LVAD-DT), is becoming increasingly commonplace. In the current case, a patient was hospitalized for complications related to his LVAD-DT requests “full code” status, despite a clinician's warning that performing chest compressions may damage the LVAD device or vascular structures leading to poor outcome. This discussion explores the ethical and legal considerations regarding a patient request for cardiopulmonary resuscitation when limited options for survival or further treatment are available.

Providing End-of-Life Care for Patients With Left Ventricular Assist Devices: Experience of a Hospice Agency

CONTEXT

Patients with left ventricular assist devices (LVADs) need expert palliative care at the end of life. In the U.S., hospice may provide this care, but few patients enroll, and information about hospice experience with LVAD-implanted patients is limited.

OBJECTIVE

To describe hospice experience with LVAD-implanted patients.

METHODS

This is a retrospective descriptive study of all LVAD-implanted patients admitted to a hospice agency. Data were extracted from the electronic health record.

RESULTS

The 13 patients had a mean age of 63 years (range 20-89) and a mean LVAD duration of 32.5 months (range 8.2-70.0). Hospice diagnosis was heart failure in 10 patients and cancer in three patients; all patients were multimorbid. Eight patients enrolled in hospice on one occasion, four had two enrollments, and one had five. All patients received services for <180 days, three for <7 days, and four patients for >90 days. Just-in-time inservicing was used to prepare hospice teams for challenging care needs, including bleeding, delirium, infections, and mechanical failure. Of the nine patients who died while receiving hospice services, one enrolled with a plan to deactivate the LVAD immediately after hospice enrollment, and six died after discontinuation of the LVAD or other life-sustaining therapy during the course of hospice care. Five deaths occurred in a hospice inpatient unit.

CONCLUSION

To provide specialist palliative care to LVAD-implanted patients, hospices must be prepared to manage complex and highly varied needs. To do this, hospices must have adequate staff support and access to acute care.

[Palliative care in patients with left ventricular assist devices: systematic review]

Hintergrund

Bei terminal herzinsuffizienten Patienten gewinnt die Implantation von Linksherzunterstützungssystemen (LVAD) als Therapieoption zunehmend an Bedeutung. Diese Systeme werden als Überbrückung bis zu einer Herztransplantation (BTT) oder als definitive Therapie (DT) eingesetzt. Sie können die Lebensqualität verbessern und die Lebenszeit verlängern. Trotzdem bleibt die Prognose besonders bei DT oder bei Wechsel von BTT zu DT mit Blick auf die Lebenszeit und auftretende Komplikationen ungünstig. Bisher ist ungeklärt, ob eine LVAD-Implantation eine Indikation für eine frühzeitige Integration von Palliativmedizin darstellt.

Ziel der Arbeit

Erfassung der aktuellen Studienlage über den Einfluss einer palliativmedizinischen Behandlung bei LVAD-Patienten.

Material und Methoden

Im Mai 2020 wurde eine systematische Literaturrecherche in 6 verschiedenen Datenbanken durchgeführt.

Ergebnisse

Von den 491 Treffern der Literaturrecherche wurden 21 Arbeiten in diese Übersichtsarbeit eingeschlossen. Durch die frühzeitige Integration der Palliativmedizin vor LVAD-Implantation erhöhte sich die Anzahl der Patienten mit vorausschauender Versorgungsplanung und Vorsorgeinstrumenten. Außerdem zeigte sich ein positiver Einfluss auf das familiäre Umfeld, das Symptommanagement und die Umstände des Versterbens. Es gibt verschiedene Formate für die Integration palliativmedizinischer Konzepte in die LVAD-Therapie.

Diskussion

Die frühzeitige und kontinuierliche Einbindung der Palliativmedizin im Verlauf einer LVAD-Therapie kann die Behandlungsqualität verbessern. Die Ausarbeitung von spezifischen Handlungsempfehlungen ist in Abhängigkeit vom Therapieziel (BTT oder DT) sinnvoll. Empfohlen werden Schulungen für Palliativmediziner und LVAD-Spezialisten.

Association Between "Unacceptable Condition" Expressed in Palliative Care Consultation Before Left Ventricular Assist Device Implantation and Care Received at the End of Life

CONTEXT

Palliative care consultation before left ventricular assist device (LVAD) surgery (PreVAD) has been recommended, but its impact on goal-concordant care is unknown.

OBJECTIVES

To describe the association between patients' unique unacceptable condition articulated during PreVAD with the actual care provided at the end of life.

METHODS

Among 308 patients who had PreVAD between 2014 and 2019, 72 patients died before December 31, 2019. Based on the answers to the question, "Is there any condition you would find unacceptable?" patients were divided into ARTICULATE (those who could articulate their unacceptable condition clearly, n = 58) and non-ARTICULATE (those who could not, n = 14). Circumstances at death and end-of-life care were compared between groups.

RESULTS

Mean age at death was 63.2 years (SD ±13.1), 56 patients (77.8%) were males, and median duration of LVAD was 167.5 days (interquartile range 682). ARTICULATE patients died less frequently in the intensive care unit than non-ARTICULATE patients (33 patients, 57.9% vs. 13 patients, 92.9%; P = 0.014) and had ethics consultation less frequently (four patients, 6.9% vs. five patients, 35.7%; P = 0.011). Frequency of LVAD withdrawal was similar in both groups. Among ARTICULATE cohort, the unacceptable condition articulated in PreVAD did not seem to influence decisions at the end of life.

CONCLUSION

Patients who articulated their unacceptable condition clearly before LVAD surgery had less frequent ethics consultations and received less intensive care at the end of life, but it did not seem to affect the decision of LVAD withdrawal. It may be more important to engage in discussions around their unacceptable conditions, rather than the specific condition articulated. The question of an unacceptable condition should be part of any routine palliative care consultation before LVAD surgery.

Palliative Care in Acute Heart Failure

Purpose of Review

Palliative care is increasingly acknowledged as beneficial in supporting patients and families affected by heart failure, but policy documents have generally focused on the chronic form of this disease. We examined palliative care provision for those with acute heart failure, based on the recently updated National Consensus Project Clinical Practice Guidelines for Quality Palliative Care.

Recent Findings

The commonest reason for hospitalization in those > 65 years, acute heart failure admissions delineate crisis points on the unpredictable disease trajectory. Palliative care is underutilized, often perceived as limited to end-of-life care rather than determined by regular systematic needs assessment. No dominant paradigm of palliative care provision has emerged from the nascent evidence base related to this clinical cohort, underscoring the need for further research.

Summary

Embedding palliative support as mainstream to heart failure care from the point of diagnosis may better ensure treatment strategies for those admitted with acute heart failure remain consistent with patients’ preferences and values.

Integration of a palliative approach into heart failure care: a European Society of Cardiology Heart Failure Association position paper

The Heart Failure Association of the European Society of Cardiology has published a previous position paper and various guidelines over the past decade recognizing the value of palliative care for those affected by this burdensome condition. Integrating palliative care into evidence-based heart failure management remains challenging for many professionals, as it includes the identification of palliative care needs, symptom control, adjustment of drug and device therapy, advance care planning, family and informal caregiver support, and trying to ensure a 'good death'. This new position paper aims to provide day-to-day practical clinical guidance on these topics, supporting the coordinated provision of palliation strategies as goals of care fluctuate along the heart failure disease trajectory. The specific components of palliative care for symptom alleviation, spiritual and psychosocial support, and the appropriate modification of guideline-directed treatment protocols, including drug deprescription and device deactivation, are described for the chronic, crisis and terminal phases of heart failure.

Life Beyond Heart Failure-What Are the Long-Term Challenges, Supportive Care Needs, and Views Toward Supportive Care of Multiethnic Asian Patients With Left Ventricular Assist Device and Their Caregivers?

CONTEXT

Challenges experienced by patients with the left ventricular assist device (LVAD) and their caregivers during the early period after LVAD implantation are well documented. However, little is known about long-term challenges, supportive care needs, and views toward supportive care of Asian LVAD patients and caregivers.

OBJECTIVES

We aimed to explore the experiences of multiethnic Asian LVAD patients and caregivers so as to identify their long-term challenges, supportive care needs, and views toward supportive care.

METHODS

Semistructured interviews with LVAD patients and caregivers were conducted based on the grounded theory approach. Participants were purposively recruited from the inpatient and outpatient settings of the National Heart Center Singapore.

RESULTS

A total of 30 patients and 11 caregivers participated. More than half of the participants were Chinese (patients 63%; caregivers 64%). Most patients (83%) were males, whereas most caregivers were females (91%). The median duration on support was 31 months and 46 months for patients and caregivers, respectively. The implantation of the LVAD was a significant milestone in their lives and caused long-term changes in multiple domains (physical, financial, social, psychoemotional, and spiritual). Experiencing permanent and recurrent losses over time was particularly challenging. Participants expressed the need for mutual support between patient and caregiver and connectedness with others and society at large. Participants desired holistic supportive care from their health care team.

CONCLUSION

Asian LVAD patients and caregivers experienced long-term challenges and had unique supportive care needs. Our findings have implications on the design of future interventions and supportive care models.

Palliative Care Engagement for Pediatric Ventricular Assist Device Patients: A Single-Center Experience

Outcomes in pediatric patients with ventricular assist devices (VADs) for advanced heart failure (HF) are improving, but the risk of associated morbidity and mortality remains substantial. Few data exist on the involvement of pediatric palliative care (PPC) in this high-risk patient population. We aimed to characterize the extent of palliative care involvement in the care of patients requiring VAD placement at our institution. Single-center retrospective chart review analyzing all VAD patients at a large pediatric center over a 4 year period. Timing and extent of palliative care subspecialty involvement were analyzed. Between January 2014 and December 2017, 55 HF patients underwent VAD implantation at our institution. Pediatric palliative care utilization steadily increased over consecutive years (2014: <10% of patients, 2015: 20% of patients, 2016: 50% of patients, and 2017: 65% of patients) and occurred in 42% (n = 23) of all patients. Of these, 57% (n = 13) occurred before VAD placement while 43% (n = 10) occurred after implantation. Patients who died during their VAD implant hospitalization (24%, n = 13) were nearly twice as likely to have PPC involvement (62%) as those who reached transplant (38%). Of those who died, patients who had PPC involved in their care were more likely to limit resuscitation efforts before their death. Four patients had advanced directives in place before VAD implant, of which three had PPC consultation before device placement. Three families (5%) refused PPC involvement when offered. Pediatric palliative care utilization is increasing in VAD patients at our institution. Early PPC involvement occurred in the majority of patients and appears to lead to more frequent discussion of goals-of-care and advanced directives.

Delineating Pathways to Death by Multisystem Organ Failure in Patients With a Left Ventricular Assist Device

BACKGROUND

This study delineates the sequences of adverse events (AEs) preceding mortality attributed to multisystem organ failure (MSOF) in patients with a left ventricular assist device (LVAD).

METHODS

We analyzed 3765 AEs after 536 LVAD implants recorded in The Society of Thoracic Surgeons Intermacs data registry between 2006 and 2015 that resulted in MSOF death. Hierarchical clustering identified and visualized quantitatively unique clusters of patients with similar AE profiles. Markov modeling was used to illustrate the AE sequences that led to MSOF death within the clusters. Cox proportional hazard models determined the risk-adjusted, preimplant predictors of MSOF.

RESULTS

We identified 2 distinct MSOF clusters based on their proportion of AE types and survival time. The early-death cluster (418 patients, 2304 AEs) had a median survival of 1 month (interquartile range, 3-6 months), whereas the late-death cluster (118 patients, 1,461 AEs) had a median survival of 11 months (interquartile range, 6-22 months). The predominant AE sequences in the early-death and late-death clusters were renal failure, to respiratory failure, to death (62%) and bleeding, to infection, to respiratory failure, to death (45%), respectively. Significant risk-adjusted preimplant predictors of MSOF included line sepsis (hazard ratio [HR] 3.0; 95% confidence interval [CI], 1.1-8.2), extracorporeal membrane oxygenation (HR, 2.2; 95% CI, 1.2-3.9), and dialysis or ultrafiltration (HR, 2.1; 95% CI, 1.5-3.0).

CONCLUSIONS

This analysis identified 2 AE clusters and the predominant sequences that result in MSOF-associated mortality. MSOF develops in 1 cluster of patients after chronic bleeding and repeated infections but has prolonged survival, while another group dies early after renal and respiratory complications.

Heart Failure: A Palliative Medicine Review of Disease, Therapies, and Medications With a Focus on Symptoms, Function, and Quality of Life

Despite significant advances in heart failure (HF) treatment, HF remains a progressive, extremely symptomatic, and terminal disease with a median survival of 2.1 years after diagnosis. HF often leads to a constellation of symptoms, including dyspnea, fatigue, depression, anxiety, insomnia, pain, and worsened cognitive function. Palliative care is an approach that improves the quality of life of patients and their caregivers facing the problems associated with life-threatening illness and therefore is well suited to support these patients. However, historically, palliative care has often focused on supporting patients with malignant disease, rather than a progressive chronic disease such as HF. Predicting mortality in patients with HF is challenging. The lack of obvious transition points in disease progression also raises challenges to primary care providers and specialists to know at what point to integrate palliative care during a patient's disease trajectory. Although therapies for HF often result in functional and symptomatic improvements including health-related quality of life (HRQL), some patients with HF do not demonstrate these benefits, including those patients with a preserved ejection fraction. Provision of palliative care for patients with HF requires an understanding of HF pathogenesis and common medications used for these patients, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes HF and current targeted therapies and their effects on symptoms, hospital admission rates, exercise performance, HRQL, and survival. Pharmacological interactions with and precautions related to commonly used palliative care medications are reviewed. The goal of this review is to equip palliative care clinicians with information to make evidence-based decisions while managing the balance between optimal disease management and patient quality of life.

Effects of high-energy photon beam radiation therapy on Jarvik 2000 LVAD: in vitro evaluation

PURPOSE

Left ventricular assist device (LVAD) is considered a standard care for patients with advanced heart failure. The aim of this work was to study in vitro the effects of direct exposure of the Jarvik 2000 LVAD to 10-MV photon beams.

METHODS

Jarvik 2000 pump was immersed in a siliconized box filled with deionized water. A 30 × 30 × 15 cm RW3 slabs were added forth and back to the box. A treatment plan consisting of a single direct 10 × 10 cm² field size beam was used to deliver 1000 MU at the center of the pump. During irradiation, the external Flow Maker controller and the lithium battery were positioned away from the beam. Pump parameter data (included voltage, current and frequency) were measured, recorded and analyzed for changes in pump function among baseline, pre-irradiation, during irradiation, post-irradiation and after 6 months. The whole session lasted 6 months. The Mann-Whitney U test was used to compare the repeated measurements. X-ray radiation attenuation was also studied.

RESULTS

The parameters investigated remained stable over the 6 months; that is, no pump stops, alarms, events, operational changes or abnormalities during the discharge rate of the connected power sources, were encountered, confirmed by the Mann-Whitney U test applied to all sessions (p > 0.1). The measured X-ray attenuation differed from the calculated one by TPS by 34%.

CONCLUSION

The Jarvik 2000 resulted stable under direct X-ray beam of 10-MV energy. Its strong attenuation, however, can affect dose deposition in the pump in TPS, and it must be taken into account.

Palliative cardiovascular care: The right patient at the right time

In the increasingly complex world of modern medicine, relationship-centered, team-based care is important in geriatric cardiology. Palliative cardiovascular care plays a central role in defining the scope and timing of medical therapies and in coordinating symptom-targeted care in line with patient wishes, values, and preferences. Palliative care addresses advance care planning, symptom relief and caregiver/family support and seeks to ameliorate all forms of suffering, including physical, psychological, and spiritual. Although palliative care grew out of the hospice movement and has traditionally been associated with care at the end of life, the current model acknowledges that palliative care can be delivered concurrent with invasive, life-prolonging interventions. As the population ages, patients with serious cardiovascular disease increasingly suffer from noncardiac, multimorbid conditions and become eligible for interventions that palliate symptoms but also prolong life. Management of implanted cardiac support devices at the end of life, whether rhythm management devices or mechanical circulatory support devices, can involve a host of complexities in decisions to deactivate, timing of deactivation and even the mechanics of deactivation. Studies on palliative care interventions have demonstrated clear improvements in quality of life and are more mixed on life prolongation and cost savings. There is and will remain a dearth of clinicians with specialist palliative care training. Therefore, cardiovascular clinicians have a role to play in provision of practical, "primary" palliative care.

Forensic Considerations in a Series of 14 Deaths of Patients with a Left Ventricular Assist Device

INTRODUCTION

To better understand the forensic implications of death with a left ventricular assist device (LVAD), we reviewed all deaths that were reported to a regional medical examiner jurisdiction involving patients who had an LVAD.

METHODS

Medical examiner case files between January 2012 and September 2018 were searched for "LVAD" and "left ventricular assist device" to identify deaths that were reported to the medical examiner involving a decedent who had an LVAD at the time of death.

RESULTS

During the study period, a total of 14 deaths were reported to the regional medical examiner involving decedents who had an implanted LVAD at the time of death. The average age at death was 64 years, with a range from 40 to 81 years. The underlying cardiac disease leading to LVAD implantation was ischemic heart disease (n = 9), nonischemic dilated cardiomyopathy (n = 4), and chemotherapy-related cardiotoxicity (n = 1). Of these 14 deaths, 2 deaths were due to loss of power to the LVAD, 1 death was due to traumatic subdural hemorrhage occurring in the setting of anticoagulation therapy required by LVAD implantation, and 1 death was due to femur fracture following a fall.

DISCUSSION

Medical examiners should be familiar with the potential complications of LVADs, especially those complications that may prompt consideration of non-natural manners of death. Medical examiners should also be aware of the tools and investigative strategies that may assist in the investigation of LVAD-related deaths.

Destination-Therapy Ventricular Assist Device in Children: "The Future Is Now"

Durable ventricular assist devices (VADs) have significantly improved survival to transplantation among children with advanced stages of heart failure. The fundamental goals of VAD therapy include decreasing mortality, minimizing adverse events, and improving quality of life. As the pediatric VAD experience has evolved with reduced device related complications and improved survival, VAD therapy is being considered not only as a bridge to transplantation (BTT) but also as a bridge to decision (BTD) and as destination therapy (DT). Data regarding pediatric DT VAD are limited to anecdotal or case reports of children being supported for long periods with VADs and by default being classified as DT VAD. This article reviews current trends in the use of DT VAD and adverse events in children vs adults on VAD, and provides a framework for patient selection with the use of a multidisciplinary approach including palliative care. The general approach to determining DT VAD candidacy should include: 1) a reasonable success that the patient will survive the peri- and postoperative state; and 2) a high likelihood that the patient will be able to be discharged out of hospital and have adequate caregiver support. Patients with muscular dystrophy and failing Fontan physiology are examples of pediatric populations for whom DT VAD may be considered and which require unique considerations.

Can Biomarkers Provide Right Ventricular-Specific Prognostication in the Perioperative Setting?

Since the introduction of biomarkers in the late 1980s, considerable research has been dedicated to their validation and application. As a result, many biomarkers are now commonly used in clinical practice. However, the role of biomarkers in the prediction of right ventricular failure (RVF) and in the prognostication for patients with RVF remains underexplored. Barriers include a lack of awareness of the importance of right ventricular function, especially in the perioperative setting, as well as a lack of reproducible means to assess right ventricular function in this setting. We provide an overview of biomarkers with right ventricular prognostic capabilities that could be further explored in patients expecting cardiac surgery, who are notoriously susceptible to developing RVF. We discuss biomarkers' mechanistic pathways and highlight their potential strengths and weaknesses in use in research and clinical care.

Cardiac Implantable Electronic Devices in Patients With Left Ventricular Assist Systems

Recent progress and evolution in device engineering, surgical implantation practices, and periprocedural management have advanced the promise of durable support with left ventricular assist systems (LVAS) in patients with stage D heart failure. With greater uptake of LVAS globally, a growing population of LVAS recipients have pre-existing cardiac implantable electronic devices (CIEDs). Strategies for optimal clinical management of CIEDs in patients with durable LVAS are evolving, and clinicians will increasingly face complex decisions regarding implantation, programming, deactivation, and removal of CIEDs. Traditional decision-making pathways for CIEDs may not apply to LVAS-supported patients, as few patients die of arrhythmic causes and many arrhythmias may be well tolerated. Given limited data, treatment decisions must be individualized and made collaboratively among electrophysiologists, advanced heart failure specialists, and patients and their caregivers. Large, prospective, well-conducted studies are needed to better understand the contemporary utility of CIEDs in patients with newer-generation LVAS.

Acute kidney injury following left ventricular assist device implantation: Contemporary insights and future perspectives

Currently, an increasing number of patients with end-stage heart failure are being treated with left ventricular assist device (LVAD) therapy as bridge-to-transplantation, bridge-to-candidacy, or destination therapy (DT). Potential life-threatening complications may occur, specifically in the early post-operative phase, which positions LVAD implantation as a high-risk surgical procedure. Acute kidney injury (AKI) is a frequently observed complication after LVAD implantation and is associated with high morbidity and mortality. The rapidly growing number of LVAD implantations necessitates better approaches of identifying high-risk patients, optimizing peri-operative management, and preventing severe complications such as AKI. This holds especially true for those patients receiving an LVAD as DT, who are typically older (with higher burden of comorbidities) with impaired renal function and at increased post-operative risk. Herein we outline the definition, diagnosis, frequency, pathophysiology, and risk factors for AKI in patients with an LVAD. We also review possible strategies to prevent and manage AKI in this patient population.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients with Left Ventricular Assist Devices

Advanced heart failure (HF) is a common condition that leads to significant suffering for patients and their families. Left ventricular assist devices (LVADs) can improve both the quantity and quality of life for those suffering with advanced HF. Palliative care clinicians are being asked with increasing frequency to assist HF teams to manage patients with LVADs in the preimplantation, post-operative, and end-of-life settings, although not all palliative care providers feel comfortable with this technology. Written by specialists in HF, geriatric cardiology, and palliative care, this article seeks to improve palliative care providers' knowledge of LVADs and will prepare palliative care teams to counsel and support LVAD patients and their families from pre-implantation to the end of life.

The Role of Palliative Care in the Cardiac Intensive Care Unit

In the last few years, important changes have occurred in the clinical and epidemiological characteristics of patients that were admitted to cardiac intensive care units (CICU). Care has shifted from acute coronary syndrome patients towards elderly patients, with a high prevalence of non-ischemic cardiovascular diseases and a high burden of non-cardiovascular comorbid conditions: both increase the susceptibility of patients to developing life-threatening critical conditions. These conditions are associated with a significant symptom burden and mortality rate and an increased length of stay. In this context, palliative care programs, including withholding/withdrawing life support treatments or the deactivation of implanted cardiac devices, are frequently needed, according to the specific guidelines of scientific societies. However, the implementation of these recommendations in clinical practice is still inconsistent. In this review, we analyze the reasons for this gap and the main cultural changes that are required to improve the care of patients with advanced illness.