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Continuous-Flow Left Ventricular Assist Device Survival Improves with Multidisciplinary Approach.
Annals of Thoracic Surgery 2019 March 8
BACKGROUND: Continuous flow-left ventricular assist devices (CF-LVADS) have revolutionized the management of advanced heart failure. Device complications continue to limit survival, but enhanced management strategies have shown promise. This study compared outcomes for HeartmateII recipients before and after implementation of a multidisciplinary continuous support Heart Team (HTMCS) strategy.
METHODS: Between 1/2012-12/2016, 124 consecutive patients underwent primary HeartmateII implantation at our institution. In 1/2015, we instituted a HTMCS approach consisting of: (1)daily simultaneous cardiology/cardiac surgery/critical care/pharmacy/coordinator rounds (2)pharmacist-directed anticoagulation (3)pre-discharge speed optimization echocardiogram (4)comprehensive device thrombosis screening and early intervention (5)blood pressure clinic with pulsatility-adjusted goals(6) early post-discharge follow-up and individual long-term coordinator/cardiologist assignment (7)systematic basic/advanced/expert training and credentialing of ancillary in-hospital providers. All patients completed one-year follow-up.
RESULTS: Demographics for pre-HTMCS (n=71) and HTMCS (n=53) groups including age (55.8±12.1 vs. 52.5±14.1 years, p=NS), percent male (77.5% vs. 71.7%, p=NS) and INTERMACS class 3 (84.5% vs. 83.0%, p=NS) were comparable. One-year survival was 74.6% vs. 100% for pre-HTMCS and HTMCS group, respectively (p=0.0002). One-year survival free of serious adverse events (reoperation to replace device or disabling stroke) was 70.4% vs. 84.9% for pre-HTMCS and HTMCS groups, respectively (p=0.059). Event per patient-year rates for disabling stroke (0.15 vs. 0, p=0.019), gastrointestinal bleeding (0.87 vs. 0.51, p=0.11), and driveline infection (0.24 vs. 0.10, p=0.18) were lower for HTMCS group, while pump thrombosis requiring device exchange was higher (0.09 vs. 0.18, p=0.14).
CONCLUSIONS: Implementing a comprehensive multidisciplinary approach substantially improved outcomes for CF-LVAD recipients.
METHODS: Between 1/2012-12/2016, 124 consecutive patients underwent primary HeartmateII implantation at our institution. In 1/2015, we instituted a HTMCS approach consisting of: (1)daily simultaneous cardiology/cardiac surgery/critical care/pharmacy/coordinator rounds (2)pharmacist-directed anticoagulation (3)pre-discharge speed optimization echocardiogram (4)comprehensive device thrombosis screening and early intervention (5)blood pressure clinic with pulsatility-adjusted goals(6) early post-discharge follow-up and individual long-term coordinator/cardiologist assignment (7)systematic basic/advanced/expert training and credentialing of ancillary in-hospital providers. All patients completed one-year follow-up.
RESULTS: Demographics for pre-HTMCS (n=71) and HTMCS (n=53) groups including age (55.8±12.1 vs. 52.5±14.1 years, p=NS), percent male (77.5% vs. 71.7%, p=NS) and INTERMACS class 3 (84.5% vs. 83.0%, p=NS) were comparable. One-year survival was 74.6% vs. 100% for pre-HTMCS and HTMCS group, respectively (p=0.0002). One-year survival free of serious adverse events (reoperation to replace device or disabling stroke) was 70.4% vs. 84.9% for pre-HTMCS and HTMCS groups, respectively (p=0.059). Event per patient-year rates for disabling stroke (0.15 vs. 0, p=0.019), gastrointestinal bleeding (0.87 vs. 0.51, p=0.11), and driveline infection (0.24 vs. 0.10, p=0.18) were lower for HTMCS group, while pump thrombosis requiring device exchange was higher (0.09 vs. 0.18, p=0.14).
CONCLUSIONS: Implementing a comprehensive multidisciplinary approach substantially improved outcomes for CF-LVAD recipients.
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