Present-Day Hospital Readmissions after Left Ventricular Assist Device Implantation: A Large Single-Center Study

Abstract

A Large Single-Center StudyLeft ventricular assist device (LVAD) C irculatory support with left ventricular assist devices (LVADs) has emerged as a powerful therapy that can improve outcomes in patients who have advanced heart failure (HF) refractory to medical therapy.1-3 The scarcity of donor organs severely limits transplantation as an option for patients with advanced HF; moreover, transplant patients need lifelong immunosuppression, the medications for which can have their own serious side effects. The newest generation of LVADs comprises continuous-flow (CF) pumps, which use axial or centrifugal technology, deliver flows of up to 10 L/min, 2,4 and are smaller and more durable than previous models. Currently, these LVADs are implanted either as a bridge to transplantation (BTT) or as destination therapy (DT), which offers a permanent alternative to transplantation.Recently, patients with end-stage HF were given new options when the U.S. Food and Drug Administration (FDA) approved 2 continuous-flow LVADs: the HeartMate ® II (Thoratec Corporation; Pleasanton, Calif ) and the HeartWare ® Ventricular Assist System (HeartWare Inc.; Framingham, Mass). The HeartMate II was approved for BTT in 2008 and for DT in 2010, and the HeartWare was approved for BTT in 2012. These milestones initiated modern LVAD therapy, enabling this treatment to become available to a larger population of patients. [5][6][7][8][9] Consequently, LVAD use has dramatically increased throughout the world, particularly for DT, and growing numbers of medical centers are offering device therapy. [9][10][11] This trend has been bolstered by reports that LVAD use, in HF patients 70 years of age or older, is associated with

Optimal Hemodynamics During Left Ventricular Assist Device Support Are Associated With Reduced Readmission Rates

“…Our findings highlight the challenge of repeated read-missions after LVAD implantation. The readmission rate in our cohort was 1.81 events/y, similar to the rates of other reports (≈2.0 events/y) [12][13][14] and serves as a reminder that adverse events remain a significant barrier to expanded use of LVADs. Baras Shreibati et al 2 have demonstrated that the costeffectiveness of LVAD therapy continues to be adversely affected by frequent readmissions.…”

Association of global and disease-specific health status with outcomes following continuous-flow left ventricular assist device implantation

“…Existing data report remarkably high hospital readmission rates after LVAD [ 33 , 34 ]. The leading causes for hospital readmission in this population range from non-cardiac comorbidities [ 35 ], gastrointestinal bleeding [ 36 ], and device component infection [ 37 ] to recurrent heart failure [ 38 ] and progression of cardiac pathology [ 37 ]. The current study represents the challenges inherent in attempting to predict a very common outcome, and the need for further study.…”

A Standardized Telephone Intervention Algorithm Improves the Survival of Ventricular Assist Device Outpatients

“…In this study, patients in the TI cohort reported a mean INR of 2.4 6 0.4 and spent 72.2% of the TTR, possibly contributing to the reduced readmission rates based on major bleeding of 20.8% (TI) versus 36.4% in the UC group. This interpretation is supported by previous reports (16,21) that bleeding is the most common postoperative event in these patients. As VAD patients with elevated MAP are at an increased risk for pump thrombus or stroke (3,4,22), another positive effect of the telephone intervention algorithm is the enhanced blood pressure management seen in the TI versus UC group, resulting in a significantly lower MAP during follow up.…”

“…Preventing these adverse events or at least detecting them at an earlier, less urgent, stage must be the focus in VAD patient management to improve outcomes. While some centers report routine phone calls or at least phone contact to the patient or caregiver in addition to consensus‐based VAD outpatient practices, this is the first study reporting the implementation of a standardized telephone intervention algorithm. By means of a graphical user interface all problems detected on call were categorized fully, automatically based on an algorithm in five levels of severity and triaged in a standardized manner by the VAD Coordinator.…”

“…At 24 months post discharge, the most common etiology for readmission was major bleeding (including gastrointestinal bleeding) in 36.4% of the UC (vs. 20.8% TI, P 5 0.20) and other causes (e.g., dizziness, malnutrition, altered mental status, abnormal blood glucose, fall or social indication) in 45.8% of the TI patients (vs. 22.7% UC, P 5 0.09). Neurological dysfunction was comparable between groups (UC 27.3% vs. TI 20.8%, P 5 0.43), although no readmission due to hemorrhagic cerebral strokes occurred in the TI group (vs. 16.1% of all neurological UC readmissions), representing the second most frequent clinical readmission profile in the UC group. 33.3% device-related driveline or pocket infections as the primary cause of readmission represented the second most frequent reason in the TI cohort and occurred significantly more often than in the UC group (33.3% vs. 4.5% UC, P 5 0.02).…”