Continuous-Flow Left Ventricular Assist Device Survival Improves With Multidisciplinary Approach

Abstract

Background. Continuous-flow left ventricular assist devices 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 HeartMate II recipients before and after implementation of a multidisciplinary continuous support heart team (HTMCS) strategy. Methods. Between January 2012 and December 2016, 124 consecutive patients underwent primary HeartMate II implantation at our institution. In January 2015, we instituted a HTMCS approach consisting of (1) daily simultaneous cardiology/cardiac surgery/critical care/ pharmacy/coordinator rounds, (2) pharmacist-directed anticoagulation, (3) speed optimization echocardiogram before discharge, (4) comprehensive device thrombosis screening and early intervention, (5) blood pressure clinic with pulsatility-adjusted goals, (6) early follow-up after discharge and individual long-term coordinator/cardiologist assignment, and (7) systematic basic/advanced/ expert training and credentialing of ancillary in-hospital providers. All patients completed 1-year of follow-up. Results. Demographic characteristics for pre-HTMCS (n [ 71) and HTMCS (n [ 53) groups, including age (55.8 ± 12.1 versus 52.5 ± 14.1 years, p [ not significant), percentage of men (77.5% versus 71.7%, p [ not significant), and Interagency Registry for Mechanically Assisted Circulatory Support class 3 (84.5% versus 83.0%, p [ not significant), were comparable. One-year survival was 74.6% versus 100% for the pre-HTMCS and HTMCS groups, respectively (p [ 0.0002). One-year survival free of serious adverse events (reoperation to replace device or disabling stroke) was 70.4% versus 84.9% for the pre-HTMCS and HTMCS groups, respectively (p [ 0.059). Event per patient-year rates for disabling stroke (0.15 versus 0, p [ 0.019), gastrointestinal bleeding (0.87 versus 0.51, p [ 0.11), and driveline infection (0.24 versus 0.10, p [ 0.18) were lower for the HTMCS group, whereas pump thrombosis requiring device exchange was higher (0.09 versus 0.18, p [ 0.14). Conclusions. Implementing a comprehensive multidisciplinary approach substantially improved outcomes for recipients of continuous-flow left ventricular assist devices.

Primary results of long‐term outcomes in the MOMENTUM 3 pivotal trial and continued access protocol study phase: a study of 2200 HeartMate 3 left ventricular assist device implants

“…The finding of reduced infections suggests that closer attention to LVAD patient care and better surveillance may contribute to ameliorating this adverse event. These observations endorse the importance of effective patient and care provider education as well as multidisciplinary ambulatory care 22 . We observed an increased early RVAD requirement in the post‐pivotal trial cohort despite similar rates of right heart failure over time.…”

“…These observations endorse the importance of effective patient and care provider education as well as multidisciplinary ambulatory care. 22 We observed an increased early RVAD requirement in the post‐pivotal trial cohort despite similar rates of right heart failure over time. Our multivariable analysis demonstrates that this reflects the sicker population enrolled and greater preponderance of transplant ineligible patients, a population likely to experience earlier haemodynamic instability.…”

Center Variability in Patient Outcomes Following HeartMate 3 Implantation: An Analysis of the MOMENTUM 3 Trial

“…Strict adherence to a comprehensive, multidisciplinary team approach at sites has been associated with improved overall LVAD patient outcomes. 17 The Society of Thoracic Surgeons-Intermacs is currently devising models to define quality outcomes after LVAD on a national scale, aiming to confidentially categorize center ranking, thereafter providing centers with individual-site data to help confidentially inform them of areas for center-level performance improvement Limitations This is a secondary analysis of MOMENTUM 3 pivotal and CAP patient data, which had specific inclusion and exclusion criteria for enrollment. The adverse events analyzed herein include both fatal and nonfatal events, so the results for the early time period may potentially be impacted by the competing risk of death.…”

In a large‐volume multidisciplinary setting individual surgeon volume does not impact LVAD outcomes

“…Such multidisciplinary management strategies have been shown to shorten length of stay, improve rates of adverse events, and even decrease mortality. 17 Current VAD volume standards from the CMS dictate that a center must have at least one surgeon with 10 VAD implants over a 3-year period, and VAD activity in the last 12 months with no criteria for additional surgeons. 19 The results of our study, alongside previous studies, on the VAD-volume relationship have broader implications for dispersal of VAD resources in the country.…”