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Due to their religious beliefs, Jehovah's Witnesses (JWs) do not accept blood products; consequently, these patients with end-stage heart failure frequently seek a center willing to perform bloodless left ventricular assist device (LVAD) implantation. We assessed the challenges JWs confront in obtaining access to care, based on our center's experience orchestrating bloodless LVAD implantation. We retrospectively reviewed the medical records of 36 patients - 18 JWs and 18 non-JWs - undergoing LVAD implantation at our center. Our findings revealed that JWs travelled a significantly greater distance to receive treatment than non-JWs (median: 293 (107.75, 667.5) vs 32.5 miles (15.3, 74.5), P = 0.006). Pre-operative characteristics, including INTERMACS profiles and re-operative status at implant, were comparable between the two groups (P > 0.05 for all). However, all JWs underwent concomitant surgeries at the time of bloodless LVAD implantation, as compared to 67% of non-JWs (P = 0.019). Length of stay, discharge location, and peri-operative outcomes were not significantly different (P > 0.05). We found that JWs currently face barriers in the availability, appropriateness, preference , and timeliness of access to care (Figure 2). In particular, being refused implantation at centers nearer to their residence causes JWs to travel excessive distances in hopes of treatment; however, long-distance travel may prolong the time until treatment and may not be an option for patients with financial or logistical challenges. Our center's experience has shown that JWs face unnecessary barriers in access to care, but they can be successfully operated on with the use of optimization protocols and open communication between the patient and care team. Further research is needed to elucidate the challenges JWs face in accessing care and identify potential solutions which balance ethical considerations with patient autonomy. [ABSTRACT FROM AUTHOR]

Purpose Post-operative pain following left ventricular assist device (LVAD) implantation is commonly managed with opioid analgesics. However, the impact of this particular therapy is unknown. The aim of this study was to compare outcomes of LVAD patients who received opioid therapy and those who did not. Methods We retrospectively reviewed all patients who underwent VAD implantation from 2014 to 2017. We divided patients into those who received opioids (OP group) and who did not (NOP group) at 3 months post LVAD implantation. At 1 year, we evaluated overall survival, as well as incidence of gastrointestinal bleeding (GIB), stroke, sepsis, driveline infection and pump thrombosis. Results Among 136 patients, 77 (57%) were in the OP group. At baseline, the OP group was younger (54 vs. 64 years, p=0.001), with a higher BMI (30.8 vs. 28, p=0.023), along with fewer males (60% vs. 81%, p=0.005), and less incidence of atrial fibrillation (23 vs. 28, p=0.018). Survival at 1 year was no different between the two groups (90% vs. 83%, p = 0.27; Figure A). The incidence of overall adverse events, stroke, driveline infection and pump thrombosis were comparable between the two groups. However, incidence of GIB (31% vs. 17%, p = 0.043) and sepsis (30% vs. 13%, p = 0.036) were significantly higher in the OP group (Figure B). Conclusion This study suggests that opioids do not negatively impact survival of the LVAD patient; however, some AEs may be negatively effected. Further research is needed linking the pathophysiology of higher adverse events with opioid use in LVAD patients. [ABSTRACT FROM AUTHOR]

Anticoagulation with coumarin derivatives in left ventricular assist device (LVAD) patients is essential to prevent hemocompatibility related adverse events (HRAEs), but is challenging due to inter- and intra-individual variability of dose response and small therapeutic window. The aim of this study was to describe differences in quality of anticoagulation, HRAEs, and outcomes in users of phenprocoumon and warfarin. This retrospective, multicenter study included 179 patients (Age: 57.4±11.8 yrs, female: 23.5%, BMI: 28.6±5.9kg/m2, HM3/HVAD: 50.8%/49.2%) implanted at the Medical University of Vienna (n=102 phenprocoumon) and University of Chicago (n=77 warfarin), between 2014 and 2018. Primary outcome was INR TTR during one-year after first follow-up visit (FFUV), secondary outcomes included all-cause mortality, freedom from- and the evaluation of independent risk factors for the occurrence of HRAEs. During follow-up, phenprocoumon vs. warfarin users had a significantly higher TTR (64.9±16.1% vs. 37.7±21.8%, p<0.001). One-year survival (86.3% vs. 89.6%, p=0.65) and freedom from HRAE (59.8% vs. 54.5%, p=0.54) were comparable to both drugs/centers, but first HRAEs occurred earlier with warfarin (126 vs. 46 days post FFUV, p=0.002). In a multivariate cox proportional hazard model, female gender [hazard ratio (HR) 2.15, 95% CI 1.12-4.11; p=0.021], no beta blockers at FFUV (HR 2.16, 95% CI 1.03-4.52; p=0.042), GI bleeding pre-implant (HR 3.41, 95% CI 1.32-9.45; p=0.018) and time between INR tests (HR 0.85, 95% CI 0.74-0.99; p=0.03) were associated with a significantly higher risk of HRAEs, but drug/device type were not independent risk factors. Despite similar working mechanism of phenprocoumon and warfarin, differences in pharmacokinetics may affect anticoagulation quality. Gender, time between INR tests, absence of beta blockers and GI bleeding pre-implant are independent risk factors for HRAEs during LVAD support. [ABSTRACT FROM AUTHOR]

Purpose Bloodless left ventricular assist device (LVAD) implantation is rarely performed in patients who refuse blood products under all circumstance including death. The aim of this study is to investigate a single center's experience with these patients regarding LVAD implantation and long term management. Methods This is a retrospective review from a single center academic institution of all patients who refused blood products and received LVADs from 2012 to 2018. Demographics, readmissions, length-of-stay, hemoglobin, INR, distance traveled for therapy, adverse events and overall survival were investigated. Results Total patients N=18. Blood products administered 0. Demographics: 10 (55%) male; age 59+/-11; 76% African American; 82% Intermacs 1-2; miles traveled for therapy 408+/- 366. Operative: devices HVAD 72%, HM2 28%; reoperation sternotomy 33%; concomitant valve procedures 88%; length of stay 22 +/-12 days. Early and late adverse events see table 1. Survival: 30 days 100%, 1 year 88%, 2 year 72%, mean duration of support 2.3 years. Conclusion This study showed that LVADs can be implanted and managed successfully in patients who refuse blood products with severe cardiogenic shock and high surgical complexity. Both short term and long term management is feasible. Refusal of blood products is not a contraindication for LVAD implantation. [ABSTRACT FROM AUTHOR]