Search

Heart failure is a growing pandemic affecting approximately 6.2 million people in the US and 15 million people worldwide. Mechanical circulatory support devices are not only a bridge to transplantation, but have become destination therapy for a large portion of this population. Given its prevalence and high morbidity and mortality leading to significant financial burden on our healthcare system, establishing strategies focused on improving therapeutic outcomes and prognosis should be prioritized. Delivering care to such a large and complex patient population poses unique challenges given the progressive care needs and extensive follow-up. Time and distance traveled are among the limiting factors that disable patients from having access to life sustaining advanced therapies such as the LVAD. This chapter aims to review the traditional care model and expand on the necessary tools and benefits of the LVAD shared care model in delivering care to previously underserved patient populations with advanced heart failure.

This case report illustrates a challenging case of worsening heart failure in a previously well-compensated patient with unclear etiology. Further workup revealed the patient’s cardiac resynchronization therapy-defibrillator (CRT-D) left ventricle (LV) lead was losing capture during positional changes. This case demonstrates the importance of device optimization, as well as electrocardiogram (ECG) monitoring to elucidate possible causes of acute systolic heart failure.

Introduction Left ventricular assist devices have become the standard of care for end-stage heart failure patients over the last decade. Most centers start the DT LVAD program without assessment of the regional need, advanced heart failure clinic, and infrastructure needed to support a DT LVAD program. The shared care model has previously been described where a patient is implanted at a regional center and then returns for complete care at the local heart failure program with similar outcomes. We explore the benefits of a novel model where a center does shared care prior to becoming a DT LVAD center. Hypothesis Benefits of Shared care LVAD site prior to transitioning into a Destination Therapy (DT) LVAD implant site. Methods Deborah Heart and lung center (DHLC) started an advanced heart failure program in 2017. Initially, advanced heart failure patients were referred to regional Destination therapy centers with a shared care model. After the implant, patients received complete care at the shared care site (DHLC). This helped the shared care site identify gaps and establish LVAD complication management services such as GI, neurology, ID, palliative care, nutrition, social work, and case management. Shared care experience lead DHLC to become a certified DT LVAD site by DNV-GL. Results From 4-2017 to 4-2020, 20 patients were implanted as a shared care model. 64% were implanted as intermacs 3 and 36 % were implanted as intermacs 1-2. 80 % of Intermacs 3 patients were discharged home and 65% of Intermacs 1-2 patients were discharged home. Over a 3year period, a total of 65 hospitalizations occurred. There were 16 GI bleeds events in a total of 31% of patients, 23% of patients had CVA events with a total of 5 events, and 5% of patients had driveline infections with 1 event. The mortality rate was 27 % with 6 mortalities in this time period. Currently, 22 patients are being followed as shared care. In 2/2019, DHLC was approved as a DT LVAD site. From 4-2019 to 5-2020, 15 patients have been implanted at DHLC with LVADS. Approximately,100 % of Intermacs 3 patients were discharged to home, and 75% of Intermacs1-2 patients were discharged to home from our LVAD site. 23 patients were hospitalized with 0% CVA events, 20% GI bleed events, and approximately 3 % driveline infections with a mortality rate were 15%. Conclusions There are currently 183 LVAD Implant sites in the US approved by CMS. Despite securing CMS approval, a significant number of sites perform less than 10 LVAD implants per year. Low implant volume has shown to increase adverse outcomes. Our experience indicates that new programs who want to start a DT LVAD program should start with a shared care to DT LVAD model. This model will help establish the infrastructure needed to support the program as well as improving outcomes. Further studies are needed to explore this model.

Background Pre-hospital electrocardiograms (ECGs) are believed to reduce time to reperfusion in ST Segment Elevation Myocardial Infarction (STEMI) patients. Little is known of their impact on clinical outcomes in a rural setting. Geisinger regional STEMI network provides percutaneous coronary intervention (PCI) care to over a 100-mile radius in rural central Pennsylvania. Methods A retrospective analysis identified 280 consecutive STEMI patients treated with PCI between 1/1/09 and 8/31/11. Comparison between two STEMI groups was performed: 205 patients who were taken by the emergency medical system (EMS) to the nearest hospital (a non-PCI center), underwent an ECG revealing a STEMI, and were transported immediately to Geisinger Medical Center (GMC) for PCI (transfer group) versus 75 patients in whom a pre-hospital ECG was obtained and who were transported by EMS directly to Geisinger for PCI, bypassing the nearest hospital that did not perform PCI (the pre-hospital ECG group). Results Analysis of baseline characteristics revealed that the pre-hospital ECG cohort was older (65 vs. 60 years); had a higher percentage of previous myocardial infarctions (MI) (28% vs. 15%), heart failure (11% vs. 4%), and prior PCI (23% vs. 13%; p

Background Right heart catheterization (RHC) is a critical part of the diagnosis and subsequent treatment of advanced heart failure and cardiogenic shock. With increasing literature supporting mechanical ventricular assist devices, hemodynamic assessment in the acute setting is paramount to improving outcomes. This study is meant to evaluate the safety of ultrasound guided Swan-Ganz catheter (USSGC) insertion when compared to RHC done in the catheterization laboratory, with respect to major adverse events. Hypothesis USSGC insertion has a similar risk of serious adverse event when compared to RHC done in the catheterization laboratory with fluoroscopy. Methods Retrospective chart analysis was performed on patients admitted to Deborah Heart and Lung Center and undergoing RHC in a one-year period from 1/1/2019 until 12/31/2019. Clinical course was monitored following the procedure for major adverse events within 48 hours. Major adverse events related to the procedure were defined as pneumothorax requiring chest tube intervention, BARC bleeding class 3-5, pulmonary artery rupture, pulmonary infarction or venous fistula. These data were then compared between the two groups. The number of delayed days from the procedure recommendation until completion between the two groups was compared using negative binomial regression. Results Of 339 patients who underwent the procedure, 216 were performed at the bedside with USSGC, and 123 performed in the catheterization lab with fluoroscopy. There were no major adverse events in either groups. Delay to procedure was significantly lower in the USSGC group (0.02 days) compared to fluoroscopic group (1.4 days) which is a reduction of 33.6 hours in the USSGC group (P Conclusions Ultrasound guided Swan-Ganz right heart catheterization at the bedside appears to be equally as safe as fluoroscopic RHC done in the catheterization laboratory, as our analysis showed no major adverse events in both groups. Additionally, we found that USSGC insertion at the bedside was performed on average 1.4 days or 33.6 hours sooner than RHC in the catheterization lab. Further prospective studies are needed to see if rapid insertion of USSGC will lead to improved clinical outcomes in the setting of cardiogenic shock and advanced heart failure.

Left atrial myxomas are rare primary cardiac tumors. Their incidence is estimated to be about 0.1% of total cases. Neurological complications resulting from cardiac myxomas are seen in 20–35% of patients. Transesophageal echocardiogram (TEE) is preferred over transthoracic echocardiogram for evaluation of left atrial myxoma. Three-dimensional (3D) echocardiography ensures better visualization of intracardiac structures. It has been used prior to surgery for diagnostic support in the surgical treatment of cardiac masses. We present a case of a 46-year-old Hispanic male who developed acute ischemic stroke of left frontal lobe and was also found to have multiple ‘silent’ cerebral infarcts in the MRI of the brain. On further workup, he was found to have a left atrial myxoma on 3D TEE. This was resected with the assistance of intra-operative 3D TEE imaging. We present this case to increase awareness and to stress at early evaluation of secondary causes of ischemic cerebrovascular accident, outside the realm of hypercoagulability. This case also exhibits the need for basic cardiac workup in young individuals who present with symptoms of intermittent palpitations or chest pain to minimize significant morbidity or mortality.Keywords: left atrial myxoma; three-dimensional transesophageal echocardiogram; acute stroke(Published: 17 February 2016)Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 29604 - http://dx.doi.org/10.3402/jchimp.v6.29604

Long-term kidney transplant graft and patient survival is often limited by cardiovascular (CV) disease. Risk factors for CV disease such as diabetes, hypertension and elevated low-density lipoprotein levels are well documented; however, the impact of low levels of high-density lipoprotein (HDL) has not been defined. We performed a retrospective chart review of 324 consecutive renal transplant recipients from 2001 to 2007 to correlate baseline HDL levels with major adverse cardiovascular events (MACEs) defined as a composite of new onset CV illness, cerebral vascular events and peripheral vascular disease. A total of 92 MACEs occurred over a total of 1913 patient years of follow-up. Low HDL cholesterol levels were noted in 58.3% of patients. Compared with those with normal HDL levels, a greater percentage of patients with low HDL levels had post-transplant MACEs (20% vs. 60% respectively) and experienced an increased rate of all cause mortality. Sixty-two percent of all MACEs occurred in patients with low HDL levels. In the low HDL group, the odds ratio for experiencing a MACE was 1.92. Therefore, HDL cholesterol may provide an important new therapeutic target to prevent vascular morbidity and mortality following renal transplantation.

To determine the safety and efficacy of administering prasugrel at the time of percutaneous coronary intervention (PCI), and switching to clopidogrel, without reloading.Prasugrel has faster onset of action and appears to be of greater benefit than clopidogrel, particularly early after PCI. However, long-term prasugrel increases bleeding. Many physicians at Geisinger Medical Center (GMC) administer prasugrel before PCI and switch to clopidogrel afterward. The safety and efficacy of this strategy has not been studied.We performed a retrospective study using electronic medical records and identified patients at GMC who underwent PCI between February 1, 2009 and January 31, 2012 and received a loading dose of prasugrel with a subsequent switch to clopidogrel, without reloading. The primary endpoint was major adverse cardiovascular event (MACE), defined as death, myocardial infarction (MI), stroke, or stent thrombosis, 7 days after the first dose of clopidogrel. Secondary endpoints included MACE at 30 days, individual MACE components at 7 and 30 days post procedure, and bleeding as defined by the Bleeding Academic Research Consortium (BARC) at 1 day and 30 days.A total of 151 patients met inclusion criteria. One patient suffered a MACE on day 7 (0.7%; 95% confidence interval, 0.03%-3.33%). One patient had an MI between 8-30 days. Two patients had BARC bleeding (type 2 and type 3b) 30 days post PCI.In this small, retrospective analysis, the results of loading patients with prasugrel for PCI and switching them to clopidogrel without a loading dose appear to be encouraging.

Pre-hospital electrocardiograms (ECGs) are believed to reduce time to reperfusion in ST Segment Elevation Myocardial Infarction (STEMI) patients. Little is known of their impact on clinical outcomes in a rural setting. Geisinger regional STEMI network provides percutaneous coronary intervention (PCI) care to over a 100-mile radius in rural central Pennsylvania.A retrospective analysis identified 280 consecutive STEMI patients treated with PCI between 1/1/09 and 8/31/11. Comparison between two STEMI groups was performed: 205 patients who were taken by the emergency medical system (EMS) to the nearest hospital (a non-PCI center), underwent an ECG revealing a STEMI, and were transported immediately to Geisinger Medical Center (GMC) for PCI (transfer group) versus 75 patients in whom a pre-hospital ECG was obtained and who were transported by EMS directly to Geisinger for PCI, bypassing the nearest hospital that did not perform PCI (the pre-hospital ECG group).Analysis of baseline characteristics revealed that the pre-hospital ECG cohort was older (65 vs. 60 years); had a higher percentage of previous myocardial infarctions (MI) (28% vs. 15%), heart failure (11% vs. 4%), and prior PCI (23% vs. 13%; p 0.05 all comparisons). Median time from EMS contact to pre-hospital ECG in the pre-hospital ECG group was 5 minutes; from pre-hospital ECG to the GMC ED was 34 minutes. Median time from first medical contact (EMS contact) to reperfusion (device activation) was 79 versus 157 minutes (P 0.001), respectively in pre-hospital ECG vs. transfer groups. Mortality in the two groups at 1 year was 4.1% in the pre-hospital ECG group versus 8.3% in the transfer group (P-value = 0.34). After adjusting for the difference in age between the two groups, the 62% reduction in 1 year mortality associated with having obtained a pre-hospital ECG was still not statistically significant (P-value = 0.19).In a rural regional STEMI network, pre-hospital ECGs decreased time from first medical contact to reperfusion by 50% and were associated with an excellent clinical outcome at 1 year. © 2016 Wiley Periodicals, Inc.

To determine whether sex-based differences exist in clinical effectiveness of percutaneous coronary intervention (PCI) when added to optimal medical therapy (OMT) in patients with stable coronary artery disease.A prior pre-specified unadjusted analysis from COURAGE showed that women randomized to PCI had a lower rate of death or myocardial infarction during a median 4.6-year follow-up with a trend for interaction with respect to sex.We analyzed outcomes in 338 women (15%) and 1949 men (85%) randomized to PCI plus OMT versus OMT alone after adjustment for relevant baseline characteristics.There was no difference in treatment effect by sex for the primary end point (death or myocardial infarction; HR, 0.89; 95% CI, 0.77-1.03 for women and HR, 1.02, 95% CI 0.96-1.10 for men; P for interaction = .07). Although the event rate was low, a trend for interaction by sex was nonetheless noted for hospitalization for heart failure, with only women, but not men, assigned to PCI experiencing significantly fewer events as compared to their counterparts receiving OMT alone (HR, 0.59; 95% CI, 0.40-0.84, P.001 for women and HR, 0.86; 95% CI, 0.74-1.01, P = .47 for men; P for interaction = .02). Both sexes randomized to PCI experienced significantly reduced need for subsequent revascularization (HR, 0.72; 95% CI, 0.62-0.83, P.001 for women; HR, 0.84; 95% CI, 0.79-0.89, P.001 for men; P for interaction = .02) with evidence of a sex-based differential treatment effect.In this adjusted analysis of the COURAGE trial, there were no significant differences in treatment effect on major outcomes between men and women. However, women assigned to PCI demonstrated a greater benefit as compared to men, with a reduction in heart failure hospitalization and need for future revascularization. These exploratory observations require further prospective study.

Long-term kidney transplant graft and patient survival is often limited by cardiovascular (CV) disease. Risk factors for CV disease such as diabetes, hypertension and elevated low-density lipoprotein levels are well documented; however, the impact of low levels of high-density lipoprotein (HDL) has not been defined. We performed a retrospective chart review of 324 consecutive renal transplant recipients from 2001 to 2007 to correlate baseline HDL levels with major adverse cardiovascular events (MACEs) defined as a composite of new onset CV illness, cerebral vascular events and peripheral vascular disease. A total of 92 MACEs occurred over a total of 1913 patient years of follow-up. Low HDL cholesterol levels were noted in 58.3% of patients. Compared with those with normal HDL levels, a greater percentage of patients with low HDL levels had post-transplant MACEs (20% vs. 60% respectively) and experienced an increased rate of all cause mortality. Sixty-two percent of all MACEs occurred in patients with low HDL levels. In the low HDL group, the odds ratio for experiencing a MACE was 1.92. Therefore, HDL cholesterol may provide an important new therapeutic target to prevent vascular morbidity and mortality following renal transplantation.