Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients with Left Ventricular Assist Devices.

Advanced heart failure (HF) is a common condition that leads to significant suffering for patients and their families. Left ventricular assist devices (LVADs) can improve both the quantity and quality of life for those suffering with advanced HF. Palliative care clinicians are being asked with increasing frequency to assist HF teams to manage patients with LVADs in the preimplantation, post-operative, and end-of-life settings, although not all palliative care providers feel comfortable with this technology. Written by specialists in HF, geriatric cardiology, and palliative care, this article seeks to improve palliative care providers' knowledge of LVADs and will prepare palliative care teams to counsel and support LVAD patients and their families from pre-implantation to the end of life.

Left Ventricular Dysfunction and Exercise Capacity Trajectory: Implications for Subclinical Heart Failure Staging Criteria.

OBJECTIVES: This study aimed to determine the association of stage B heart failure (SBHF) and its constituent left ventricular (LV) abnormalities with trajectory of exercise capacity over time, and assess whether this association is modified by reversion of these LV abnormalities to normal. BACKGROUND: The LV abnormalities of SBHF may coincide with a reduction in exercise capacity that precedes the overt exercise intolerance of clinical heart failure (HF). Determining the predictive capacity of established and novel SBHF criteria for exercise capacity decline may improve HF risk stratification. METHODS: LV structure/function (echocardiography) and exercise capacity (6-min walk distance [6MWD]) were assessed at baseline and 3-year follow-up in 268 patients from the NIL-CHF (Nurse-led Intervention for Less Chronic Heart Failure) study (all stage A [SAHF] or SBHF). Changes (Δ) in 6MWD were compared between SAHF and SBHF and across each of 4 constituent components of SBHF: LV hypertrophy, regional wall motion abnormality(ies) (RWMA), left ventricular systolic dysfunction (LVSD) (ejection fraction <45%) and elevated early diastolic filling/annular velocity ratio (E/e' ≥15). RESULTS: Δ6MWD was similar in those with SAHF (n = 141) and SBHF (n = 127; -5 m [95% confidence interval (CI): -21 to +11 m]; covariate-adjusted). However, within the setting of SBHF there was substantive heterogeneity; that is, reductions in 6MWD were observed with persistent elevated E/e' (-34 m [95% CI: -62 to -6 m]) and persistent LVSD (-41 m [95% CI: -74 to -8 m]), but not with LV hypertrophy (+17 m [95% CI: -15 to +49 m) or RWMA (+5 m [-27 to +36 m]), nor in patients whose elevated E/e' or LVSD reverted to normal by 3 years (p > 0.10). CONCLUSIONS: Elevated E/e' is associated with a similar degree of exercise capacity decline to LVSD, supporting that both LV functional criteria be considered in distinguishing SBHF from SAHF. That reversion of either manifestation of LV dysfunction was associated with preserved exercise capacity advocates targeting of these factors by HF preventive interventions.

Cardiac support devices.

Heart failure is an increasingly common condition in the United States and is associated with high mortality and burden to health care. It is a chronic condition that is characterized by progressive left ventricular enlargement. While medical therapy can slow the progression of left ventricular remodeling, surgical approaches to treatment have been developed to improve the survival and quality of life of heart failure patients. This article reviews the surgical procedures for left ventricular dysfunction and focuses on cardiac support devices as a new therapy for heart failure patients. The nursing care of patients with cardiac support devices will be presented and a case study will highlight practical points to help guide patient care.

Mental health and medical challenges. Management of a depressed patient with a left ventricular assist system in an inpatient psychiatric setting.

A depressed patient with a left ventricular assist device (LVAD) due to heart failure presented a unique challenge for staff in an inpatient psychiatric facility. Although depression in this patient population has been recognized and treated on an outpatient basis, the example described in this article may be the first known case to be treated in an acute inpatient psychiatric hospital setting. A variety of steps had to be taken to ensure the highest standards of care, as well as an optimal outcome for this patient. In addition to the individualized plan of care for depression, a more medically oriented and technologically advanced plan of care was also instituted. The inpatient psychiatric setting provides the necessary care and treatment to help the patient move beyond severe depression to engage in activities essential for health and the proper care and function of the LVAD. This article highlights an unusual psychiatric-mental health nursing situation to help others who may face this challenge in the future.

Multidisciplinary management of elderly patients with chronic heart failure: five year outcome measures in death and survivor groups.

BACKGROUND: The utility of multidisciplinary chronic disease evaluation measures, especially health related quality of life (HRQL), for long long-term prognostic use in elderly patients with heart failure is uncertain. AIM: To report on clinical, functional and HRQL values of deceased and surviving patients of a 6-month RCT of Cardiac Rehabilitation in addition to specialist nurse outpatient clinic at 5 years. METHODS: The original measures (walk test, Borg RPE, MLHF, EuroQol score and vas, biochemistry) were repeated for patients in a satisfactory condition. RESULTS: Five year survival was characterised by significantly better baseline values for LV dysfunction and NYHA class and 6-month values for MLHF, physical function and biochemistry measures. EuroQuol scores were worse than baseline for surviving patients at 5 years, in contrast to MLHF scores. The walk test gave the highest 5-year relative mortality risk, whereas the MLHF gave similar values to the Borg and uric acid measures. Deaths were more evident in normal weight older patients than in younger obese patients. CONCLUSION: Changes in patient measures were evident over 5 years and most differentiated between survivor and deceased groups. In comparison to the use of the MLHF and EuroQuol-vas, the EuroQuol score was limited by impairments of the ageing process.

Electrocardiographic evaluation of cardiovascular status.

The electrocardiogram (ECG) is indispensable for the diagnosis and management of patients with a wide variety of cardiac and noncardiac diseases. The purpose of this paper is focused on recent research that used ECG, specifically the long-QT interval and microvolt T wave alternans, for the evaluation of life-threatening ventricular arrhythmias. Although remaining to be validated, QT prolongation along with other emerging electrocardiographic indices such as T wave morphology, T peak-to-T end time, or beat-to-beat QT variability may be sensitive indicators of malignant polymorphic ventricular tachyarrhythmia, torsade de pointes. Microvolt T wave alternans may provide important information in identifying a low-risk group with left ventricular dysfunction who is unlikely to benefit from unnecessary prophylactic implantable cardioverter defibrillator therapy. These ECG markers have the potential to aid in the safe administration of individualized medications, avoidance of sudden cardiac death, and provision of a noninvasive strategy to identify patients who are most and least likely to benefit from expensive prophylactic implantable cardioverter defibrillator placement.

Effectiveness of echocardiographic imaging by nurses to identify left ventricular systolic dysfunction in high-risk patients.

Recognizing left ventricular (LV) systolic dysfunction is critical. The investigators sought to evaluate whether nurses could be trained to use a hand-carried ultrasound (HCU) device to screen for LV systolic dysfunction in high-risk patients. Sixty-three patients from an outpatient diabetes clinic underwent brief echocardiographic examinations by nurses using HCU devices. Of the 63 patients enrolled in the study, 3 (4.7%) had LV systolic dysfunction. The nurses correctly identified these 3 patients as having LV systolic dysfunction (sensitivity 100%, negative predictive value 100%). The identification of occult LV systolic dysfunction in diabetic patients may allow the initiation of therapies known to improve prognosis.

Bridging the treatment gap: the secondary care perspective.

Protocols and integrated care pathways can be valuable in the hospital care of patients with heart failure or left ventricular systolic dysfunction after acute myocardial infarction. A designated member of staff, often a specialist nurse, must be responsible for identifying patients suitable for management by the protocol and for ensuring that the protocol is adhered to. A new training scheme for "limited echocardiography" might enable specialist nurses to investigate left ventricular function within the first 24 hours of admission. Patients should be discharged from hospital as soon as they are out of danger. At present, they are often kept in hospital for process reasons. A "continuing care" clinic run by a specialist nurse, where patients can be seen daily after discharge until they are stabilised, is one way of bridging the gap between secondary and primary care. Communication between secondary and primary care needs to improve and same day discharge summaries are essential.

Preventing sudden cardiac death in post myocardial infarction patients with left ventricular dysfunction.

Cardiovascular nurses play a key role in caring for the post myocardial infarction (MI) patient. That role includes reducing the risk of MI recurrence and the progression to heart failure. Equally important is evaluating for the risk of sudden cardiac death (SCD). Although drugs such as beta blockers and angiotensin converting enzyme (ACE) inhibitors are typically indicated to help reduce the risk of SCD, data continue to show that using implantable cardioverter defibrillators (ICDs) saves lives compared with using medications alone. This article focuses on the problem of SCD, the findings of recent clinical trials, the implant criteria for defibrillators, new Centers for Medicare & Medicaid Services (CMS) decisions regarding reimbursement, and postoperative care for the defibrillator patient. Included are 2 case studies demonstrating the nurses' role in identifying asymptomatic patients who are indicated for ICD therapy. It is critical that cardiovascular nurses be aware of the latest scientific evidence showing improved outcomes for post-MI patients, particularly those with left ventricular dysfunction.

Left ventricular assist devices as destination therapy.

Although an estimated 16,500 Americans annually could benefit from a heart transplant, in 1999 only 2184 heart transplants were performed in the United States. These statistics emphasize the severity of the shortage of available hearts for transplantation. Circulatory support provided by an implantable Left Ventricular Assist Device (LVAD) that meets Food and Drug Administration approval as destination therapy is a promising alternative that impacts patient survival. As medical technology creates smaller implantable battery-powered circulatory assist devices that allow patients to safely live independently in the community, nursing's role must change in response. Long-term LVAD patients require strategic, anticipatory planning for extended care and emergency preparedness for mechanical support. Therefore, practitioners must familiarize themselves with these devices as they care for larger numbers of patients with implanted LVADs who require assessment and treatment of noncardiac problems during their lengthened lifespan.

Current and potential applications of left ventricular assist devices.

The syndrome of heart failure is epidemic, causing increased hospital admissions, poor survival rates, and a dismal quality of life. Treatment choices include pharmacologic, psychological, and surgical interventions. Recent data suggest that mechanical heart pumps, or assist devices, are viable additions or alternatives to transplantation in management of advanced heart failure. A ventricular assist device (VAD) can support the circulation when the natural heart is unable to maintain adequate perfusion. Although its use continues to be explored, VADs can be used in three ways: as a bridge to transplantation, as a destination therapy (or implanted permanently), or as a bridge to recovery. As VAD science advances, nurses will needs to understand its practice implications.

Perceived learning needs of patients with heart failure.

OBJECTIVE: To determine the perceived learning needs of patients with heart failure (HF) compared with identified needs by registered nurses (RNs). DESIGN: Descriptive, comparative. SETTING: Two midwestern hospitals: 1 community hospital and 1 that is part of a large, university-affiliated, integrated health care system. SAMPLE: A convenience sample of 84 adult patients with HF from left ventricular systolic dysfunction and 84 registered nurses. OUTCOME MEASURE: The Heart Failure Learning Needs Inventory, developed for this study, was used to rate 98 individual items divided into 8 subscales suggested in the Agency for Health Care Policy and Research (AHCPR) practice guidelines. The subscales include general HF information, psychologic adaptation to illness, risk factors, medications, diet, activity, prognosis, and signs and symptoms. RESULTS: Multivariate analysis of variance was completed. The patients perceived the subscales of general HF information, risk factors, medications, prognosis, and signs and symptoms as more important to learn than the RNs did (P <.05). Patients perceived diet information as less important to learn than the RNs did (P <. 05). There were no differences in the patients' and nurses' perceptions in the activity and psychologic subscales. The patients perceived all 8 subscales as more realistic to learn than the RNs did (P <.05). Although not in identical order, both groups ranked education related to medication and signs and symptoms as the 2 priority areas. Diet information was ranked eighth by the patients and third by the RNs. CONCLUSION: The findings are consistent with previous research supporting the overall trend that patients with HF perceived patient education to be more important and realistic to learn during hospitalization than the nurses did. Patients and nurses identified education related to signs and symptoms and medication as the 2 most important content areas. In comparison with the AHCPR clinical practice guidelines, the group of RNs studied would ascribe the additional category of signs and symptoms as essential content to be taught during hospitalization.

[Difficult weaning from mechanical ventilation: a graduated approach and teamwork]. / Moeizaam ontwennen van de beademing: maatwerk en teamwerk.

Weaning from mechanical ventilation in patients with chronic obstructive pulmonary disease (COPD) or left ventricular failure may be difficult. At the time of intubation and initiation of mechanical ventilatory support, this treatment is usually life-saving in the short term. Only later on, the condition which necessitated such support may prove irreversible. COPD patients often require positive end-expiratory pressure to enable them to trigger the ventilator comfortably. Patients with left ventricular failure need pharmacological support to reduce the circulating volume and to reduce left ventricular afterload because the ventilatory support itself reduces both left ventricular preload and afterload. Gradual withdrawal of pressure support and gradually increasing periods of T-piece weaning are probably equally effective. New methods have been described but have not yet been tested in randomized controlled trials. More important than the method of weaning is the presence of qualified and dedicated nursing support. Not all patients can be weaned; for most of those who cannot, prospects are grim. These patients require optimal palliative support with recognition of their autonomy.

Surgical therapy for heart failure: care of the patient with partial left ventriculectomy.

Partial left ventriculectomy (PLV) surgery has gained significant attention worldwide as a possible alternative to heart transplantation or as a therapy to treat heart failure. This procedure offers an attractive choice to patients and physicians because of the lack of need for immunosuppressive medications and a decrease in the risk of rejection associated with transplantation. PLV surgery is currently under investigation in several centers worldwide, but long-term outcomes have yet to be definitively evaluated. The Cleveland Clinic Foundation began performing PLV surgery in May 1996. Since that time, 57 patients have received the procedure with actuarial survival of 82% at 1 year. The purpose of this article is to highlight the clinical management of the postoperative PLV patient.