A right ventricular assist device (RVAD) using a dual-lumen percutaneous cannula inserted through the right internal jugular vein (IJV) might improve weaning in patients with refractory right ventricular (RV) failure. However, the reported experience with this cannula is limited. We reviewed the records of all patients receiving RVAD support with this new dual-lumen cannula at our institution between April 2017 and February 2019. We recorded data on weaning, mortality, and device-specific complications. We compared outcomes among three subgroups based on the indications for RVAD support (postcardiotomy, cardiogenic shock, and primary respiratory failure) and against similar results in the literature. Mean (standard deviation [SD]) age of the 40 patients (29 men) was 53 (15.5) years. Indications for implantation were postcardiotomy support in 18 patients, cardiogenic shock in 12, and respiratory failure in 10. In all, 17 (94%) patients in the postcardiotomy group were weaned from RVAD support, five (42%) in the cardiogenic shock group, and seven (70%) in the respiratory failure group, overall higher than those reported in the literature (49% to 59%) for surgically placed RVADs. Whereas published in-hospital mortality rates range from 42% to 50% for surgically placed RVADs and from 41% to 50% for RVADs with percutaneous cannulas implanted through the right IJV, mortality was 11%, 58%, and 40% in our subgroups, respectively. There were no major device-related complications. This percutaneous dual-lumen cannula appears to be safe and effective for managing refractory RV failure, with improved weaning and mortality profile, and with limited device-specific adverse events.
We studied whether sustained hemodynamic support (>7 d) with the Impella 5.0 heart pump can be used as a bridge to clinical decisions in patients who present with cardiogenic shock, and whether such support can improve their outcomes. We retrospectively reviewed cases of patients who had Impella 5.0 support at our hospital from August 2017 through May 2019. Thirty-four patients (23 with cardiogenic shock and 11 with severely decompensated heart failure) underwent sustained support for a mean duration of 11.7 ± 9.3 days (range, ≤48 d). Of 29 patients (85.3%) who survived to next therapy, 15 were weaned from the Impella, 8 underwent durable left ventricular assist device placement, 4 were escalated to venoarterial extracorporeal membrane oxygenation support, and 2 underwent heart transplantation. The 30-day survival rate was 76.5% (26 of 34 patients). Only 2 patients had a major adverse event: one each had an ischemic stroke and flail mitral leaflet. None of the devices malfunctioned. Sustained hemodynamic support with the Impella 5.0 not only improved outcomes in patients who presented with cardiogenic shock, but also provided time for multidisciplinary evaluation of potential cardiac recovery, or the need for durable left ventricular assist device implantation or heart transplantation. Our study shows the value of using the Impella 5.0 as a bridge to clinical decisions.
Background: Heart failure (HF) is one of the most common reasons for hospital admission in the United States. Typically, congestion is the primary reason for HF decompensation. Ambulatory pulmonary artery pressure (PAP) monitoring has been shown to reduce HF hospitalizations in clinical trials. Hypothesis: Real world application of CardioMEMS technology in a community hospital setting will result in reduction in HF hospitalizations. Methods: 26 patients (age 66.7 ± 9.84; 15 male; 85% HF Preserved EF) who underwent CardioMEMS device implantation between February, 2015 and February, 2016 were retrospectively reviewed. Patients enrolled were at least 60 days post implant. Baseline demographics, hospitalizations, and office based interventions were recorded. Implanted patients had an average of 6.7 ± 1.5 major comorbid conditions. One patient died following 197 days of monitoring from a non-cardiac cause. Patients were compared to their own 1 year historic control and evaluated in patient years for statistical analysis. Results: Patients who underwent CardioMEMS implantation had a reduction in all cause admissions from 3 to 2.5 per patient year (P = .5). Heart failure admissions were also reduced from 1.9 to 0.5 per patient year (P < .001). Total all cause hospitalized days decreased from 17.3 ± 14.3 to 8.5 ± 12.3 (P = .02) and heart failure days decreased from 12 ± 10.5 to 2.4 ± 7.7 (P < .001). This reduction was associated with an increased intensity of office interventions. Phone calls per week increased from 1.4 ± 1.7 to 2.7 ± 1.3 (P < .001), medication changes per week increased from 0.6 ± 0.6 to 1 ± 0.8 (P = .03), and office visits per month rose minimally 0.9 ± 0.5 to 1.1 ± 0.6 (P = .13). Conclusions: Ambulatory hemodynamic monitoring of PAP for a high-risk patient population, in the community hospital setting, has demonstrated a reduction of heart failure admissions. Managing an increased volume of phone calls and medication changes both significantly reduced the number of hospitalizations for HF, and time spent in the hospital for those admissions. In the current era of healthcare reform, process improvement and integration of technology into clinical practice are critical to delivering the best patient outcomes. Studies addressing efficiencies in heart failure program monitoring are needed to further propel current practice toward improved outcomes for heart failure populations.
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