The impact of race on utilization of durable left ventricular assist device therapy in patients with advanced heart failure
Mandisa‐Maia JonesLisa M. McElroyManal MirrehMatthew FullerRebecca SchroederKamrouz GhadimiAdam D. DeVoreChetan B. PatelEric Black‐MaierRaquel BartzKevin L. Thomas
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Heart failure affects >6 million people in the United States alone and is most prevalent in Black patients who suffer the highest mortality risk. Yet prior studies have suggested that Black patients are less likely to receive advanced heart failure therapy. We hypothesized that Black patients would have decreased rates of durable left ventricular assist device (LVAD) implantation within our expansive heart failure program.Keywords:
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Cardiogenic shock is associated with substantial morbidity and mortality. Although inotropic support is a mainstay of medical therapy for cardiogenic shock, little evidence exists to guide the selection of inotropic agents in clinical practice.
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Left Ventricular Assist Device (LVAD) for Destination Therapy (DT) is an established therapy for end stage heart failure patients who are not transplant candidates. Many DT patients requiring LVADs have had prior open heart surgery, the majority of whom had prior sternotomy. In addition, DT patients tend to be older and more likely to have more significant co-morbidities than their Bridge-To-Transplant (BTT) counterparts. As such, placement of an implantable LVAD in DT patients can be technically hazardous and potentially prone to more perioperative complications. The purpose of this report is to describe an alternative implantation approach for the implantation of the Heartmate II™ LVAD in high risk DT patients.
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Left-ventricular assist device (LVAD) therapy is a growing mechanical circulatory support therapy used to treat patients with advanced heart failure. There is a general assumption among clinicians that patients would prefer to accept a heart to any other treatment were they eligible. However, little research has been done to clarify the nuances of patient treatment preferences for LVAD therapy versus transplantation. The objective of this study was to investigate this treatment preference assumption from patients' perspectives. In a single-site study, 15 LVAD patients, 15 LVAD candidates, 15 LVAD decliners, and 15 LVAD caregivers (n = 60) participated in structured, in-depth interviews to assess decisional processes and treatment preferences for advanced heart failure. The interview guides were consistent with the Ottawa framework on decision-making processes. All participants were identified by the LVAD coordination team and recruited consecutively between February and November 2014. The patient and candidate groups included both LVAD designations: destination therapy (n = 22), bridge-to-transplant (n = 4), as well as four participants who deferred designation pending worsening clinical status. The interviews were analyzed using qualitative description with constant comparisons, aided by ATLAS.ti. Although LVAD eligible patients generally show a preference for heart transplantation as the ideal treatment for heart failure, some patients begin to show ambivalence as they experience LVAD therapy and begin to prefer LVAD as a long-term, destination treatment. Some themes that emerged from the interviews concerning transplantation centered on the consequences of multiple major surgeries (i.e., LVAD placement followed by heart transplantation, n = 18), fears surrounding lifestyle changes of accepting a heart transplant (n = 14) and life satisfaction with an LVAD as a "new normal" (n = 18). Findings suggest that experience with an LVAD can sometimes cause ambivalence about transplant with some patients preferring LVAD as destination even when transplant is an option. We provide clinical and programmatic implications of this, concluding with practical recommendations for how to fully address patients' goals of treatment as their health and situation changes over time.
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This is a focused review looking at the pharmacological support in cardiogenic shock. There are a plethora of data evaluating vasopressors and inotropes in septic shock, but the data are limited for cardiogenic shock. This review article describes in detail the pathophysiology of cardiogenic shock, the mechanism of action of different vasopressors and inotropes emphasizing their indications and potential side effects. This review article incorporates the currently used specific risk-prediction models in cardiogenic shock as well as integrates data from many trials on the use of vasopressors and inotropes. Lastly, this review seeks to discuss the future direction for vasoactive medications in cardiogenic shock.
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Purpose of review Cardiogenic shock is a multifactorial and diverse entity in which inotropes are the cornerstone therapy. Although published clinical trials have focused on pharmacologic treatment of cardiogenic shock, there is lack of an established and widely accepted decision-making algorithm on the use of inotropic agents in cardiogenic shock. Recent findings The current review incorporates cardiogenic shock pathophysiology, inotropes and vasopressors pharmacodynamics. It emphasizes on each agent's indications, potential adverse effects, highlights special considerations and fsummarizes the recent guidelines. Summary Finally, proposes an algorithm of inotropes and vasopressors use and their potential combinations based on the clinical stage of cardiogenic shock. This algorithm can be used as a guide during the initial management of cardiogenic shock while underlying cause investigation is underway.
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The left ventricular assist device originated as a means to provide temporary circulatory support for patients suffering from end-stage heart failure. The device was originally intended to serve as a bridge to cardiac transplantation. Increasingly, however, the left ventricular assist device is being utilized as a destination therapy for those patients who are not candidates for heart transplantation. It is this utilization as a destination therapy that raises additional significant ethical concern related to the risks and benefits of the devices, factors influencing quality of life, and consequences pertaining to end-of-life care.
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Abstract Aims The need for the left ventricular assist devices (LVAD) in patients with end‐stage heart failure is well established, but prior to 2011, this was not available to patients in Kazakhstan. We describe the development of the sole LVAD programme in the context of a nascent heart transplantation programme and clinical outcomes for the first three years. Methods and results From November 2011 to November 2014, 146 patients underwent implantation of 152 VADs (approximately 50 devices implanted per year). We retrospectively analyzed data from 135 LVAD patients who received HeartMate II ( n = 95) or HeartWare ( n = 40) devices. In 75 patients LVAD was used as a bridge‐to‐transplantation and in 60 patients as destination therapy, but only 3 of 135 LVAD patients received heart transplant. Forty‐three patients of the LVAD cohort had died by the end of the follow‐up period. The mean time on LVAD was 466 ± 330 days (range 5–1200 days). Kaplan–Meier survival estimates for patients who continued on LVAD support were 93% after 1 month, 86% after 6 months and 77% after 12 months. The most common complications within the first 30 days after implant included right ventricular failure ( n = 20, 1.85 events/patient‐year), renal failure ( n = 19, 1.76 events/patient‐year) and bleeding ( n = 33, 3.0 events/patient‐year). Beyond 30 days adverse events included driveline infections ( n = 46, 0.56 events/patient‐year) and stroke ( n = 33, 0.21 events/patient‐year). Conclusions LVADs are an important therapeutic alternative to heart transplantation in the context of a developing heart transplant programme with outcomes that are comparable to those reported by other centres.
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