Waitlist Outcomes for Pediatric Heart Transplantation in the Current Era: An Analysis of the Pediatric Heart Transplant Society Database.

BACKGROUND: Waitlist mortality (WM) remains elevated in pediatric heart transplantation. Allocation policy is a potential tool to help improve WM. This study aims to identify patients at highest risk for WM to potentially inform future allocation policy changes. METHODS: The Pediatric Heart Transplant Society database was queried for patients <18 years of age indicated for heart transplantation between January 1, 2010 to December 31, 2021. Waitlist mortality was defined as death while awaiting transplant or removal from the waitlist due to clinical deterioration. Because WM is low after the first year, analysis was limited to the first 12 months on the heart transplant list. Kaplan-Meier analysis and log-rank testing was conducted to compare unadjusted survival between groups. Cox proportional hazard models were created to determine risk factors for WM. Subgroup analysis was performed for status 1A patients based on body surface area (BSA) at time of listing, cardiac diagnosis, and presence of mechanical circulatory support. RESULTS: In total 5974 children met study criteria of which 3928 were status 1A, 1012 were status 1B, 963 were listed status 2, and 65 were listed status 7. Because of the significant burden of WM experienced by 1A patients, further analysis was performed in only patients indicated as 1A. Within that group of patients, those with smaller size and lower eGFR had higher WM, whereas those patients without congenital heart disease or support from a ventricular assist device (VAD) at time of listing had decreased WM. In the smallest size cohort, cardiac diagnoses other than dilated cardiomyopathy were risk factors for WM. Previous cardiac surgery was a risk factor in the 0.3 to 0.7 m2 and >0.7 m2 BSA groups. VAD support was associated with lower WM other than in the single ventricle cohort, where VAD was associated with higher WM. Extracorporeal membrane oxygenation and mechanical ventilation were associated with increased risk of WM in all cohorts. CONCLUSIONS: There is significant variability in WM among status-1A patients. Potential refinements to current allocation system should factor in the increased WM risk we identified in patients supported by extracorporeal membrane oxygenation or mechanical ventilation, single ventricle congenital heart disease on VAD support and small children with congenital heart disease, restrictive cardiomyopathy, or hypertrophic cardiomyopathy.

Percutaneous Microaxial Ventricular Assist Device Versus Intra-Aortic Balloon Pump for Nonacute Myocardial Infarction Cardiogenic Shock.

BACKGROUND: Evidence on the comparative outcomes following percutaneous microaxial ventricular assist devices (pVAD) versus intra-aortic balloon pump for nonacute myocardial infarction cardiogenic shock is limited. METHODS AND RESULTS: We included 704 and 2140 Medicare fee-for-service beneficiaries aged 65 to 99 years treated with pVAD and intra-aortic balloon pump, respectively, for nonacute myocardial infarction cardiogenic shock from 2016 to 2020. Patients treated using pVAD compared with those treated using intra-aortic balloon pump were more likely to be concurrently treated with mechanical ventilation, renal replacement therapy, and blood transfusions. We computed propensity scores for undergoing pVAD using patient- and hospital-level factors and performed a matching weight analysis. The use of pVAD was associated with higher 30-day mortality (adjusted odds ratio, 1.92 [95% CI, 1.59-2.33]) but not associated with in-hospital bleeding (adjusted odds ratio, 1.00 [95% CI, 0.81-1.24]), stroke (adjusted odds ratio, 0.91 [95% CI, 0.56-1.47]), sepsis (OR, 0.91 [95% CI, 0.64-1.28]), and length of hospital stay (adjusted mean difference, +0.4 days [95% CI, -1.4 to +2.3]). A quasi-experimental instrumental variable analysis using the cross-sectional institutional practice preferences showed similar patterns, though not statistically significant (adjusted odds ratio, 1.38; 95% CI, 0.28-6.89). CONCLUSIONS: Our investigation using the national sample of Medicare beneficiaries showed that the use of pVAD compared with intra-aortic balloon pump was associated with higher mortality in patients with nonacute myocardial infarction cardiogenic shock. Providers should be cautious about the use of pVAD for nonacute myocardial infarction cardiogenic shock, while adequately powered high-quality randomized controlled trials are warranted to determine the clinical effects of pVAD.

Study on the optimal elastic modulus of flexible blades for right heart assist device supporting patients with single-ventricle physiologies.

Background: Patients with single-ventricle physiologies continue to experience insufficient circulatory power after undergoing palliative surgeries. This paper proposed a right heart assist device equipped with flexible blades to provide circulatory assistance for these patients. The optimal elastic modulus of the flexible blades was investigated through numerical simulation. Methods: A one-way fluid-structure interaction (FSI) simulation was employed to study the deformation of flexible blades during rotation and its impact on device performance. The process began with a computational fluid dynamics (CFD) simulation to calculate the blood pressure rise and the pressure on the blades' surface. Subsequently, these pressure data were exported for finite element analysis (FEA) to compute the deformation of the blades. The fluid domain was then recreated based on the deformed blades' shape. Iterative CFD and FEA simulations were performed until both the blood pressure rise and the blades' shape stabilized. The blood pressure rise, hemolysis risk, and thrombosis risk corresponding to blades with different elastic moduli were exhaustively evaluated to determine the optimal elastic modulus. Results: Except for the case at 8,000 rpm with a blade elastic modulus of 40 MPa, the pressure rise associated with flexible blades within the studied range (rotational speeds of 4,000 rpm and 8,000 rpm, elastic modulus between 10 MPa and 200 MPa) was lower than that of rigid blades. It was observed that the pressure rise corresponding to flexible blades increased as the elastic modulus increased. Additionally, no significant difference was found in the hemolysis risk and thrombus risk between flexible blades of various elastic moduli and rigid blades. Conclusion: Except for one specific case, deformation of the flexible blades within the studied range led to a decrease in the impeller's functionality. Notably, rotational speed had a more significant impact on hemolysis risk and thrombus risk compared to blade deformation. After a comprehensive analysis of blade compressibility, blood pressure rise, hemolysis risk, and thrombus risk, the optimal elastic modulus for the flexible blades was determined to be between 40 MPa and 50 MPa.

Conservative Management of LVAD-Associated Ventricular Pseudoaneurysm.

Left ventricular assist devices (LVAD) are surgically implanted mechanical support devices utilized with increasing frequency as a bridge to myocardial recovery, destination therapy, and heart transplantation. While the use of such devices in patients with advanced heart failure has shown significant survival benefits and improved quality of life, they bear their own risks and complications.1 Bleeding, infection, pump thrombosis, and stroke are just some of the serious complications associated with LVADs.2 LVAD-associated pseudoaneurysms are rare, with prior reports of occurrence at the left ventricular apex and at the anastomosis site of the outflow graft to the ascending aorta.3,4 Typically, this device-related complication requires surgical repair and, if at all feasible, heart transplantation. However, in cases of difficult anatomy, unfavorable position, and significant comorbidities, surgery may be contraindicated due to high surgical risk. This case portrays a patient suffering from a left ventricular pseudoaneurysm after HeartMate-III implantation that was not amenable to surgical repair due to heightened surgical risk. We document the first pseudoaneurysm associated with the HeartMate-III in available literature and describe a novel management strategy of documented nonoperative course of LVAD-associated pseudoaneurysm, with the patient surviving 56+ months with medical optimization and management.

Warfarin and aspirin versus warfarin alone for prevention of bleeding and thrombotic events in patients with a HeartMate 3™ left ventricular assist device.

BACKGROUND: We conducted a single-center, retrospective comparison of adult patients who received warfarin and ASA or warfarin alone after HeartMate 3 (HM3) LVAD placement. METHODS: The primary outcome was a composite of bleeding and thrombotic events. RESULTS: Of 81 patients, 53 patients received warfarin and ASA, and 28 patients received warfarin alone. A primary outcome event occurred in 22 of 53 patients (41.4%) in the warfarin and ASA group and in 2 of 28 patients (7.1%) in the warfarin alone group (p = 0.0533). The odds of a bleeding event occurring were higher in the warfarin and ASA group (32.1% vs. 7.1%, p = 0.01309). The odds of a thrombotic event occurring were not significantly different between the warfarin and ASA group and the warfarin alone group (9.4% vs. 0%, respectively, p = 0.1582). CONCLUSION: The complete omission of ASA from the antithrombotic regimen of patients with a HM3 LVAD was associated with less bleeding events without an increase in thrombotic events.

Subclavian Impella 5.5 implant for perioperative left ventricular dysfunction.

We present the implant method and the postoperative management for an Impella 5.5 device via the right subclavian artery in a 72-year-old patient with severe left ventricular dysfunction upon weaning from cardiopulmonary bypass during a cardiac surgery procedure.

Upgrading extra corporeal life support to ECMELLA using Impella 5.0 in rescued INTERMACS 1 patients, lactate level matters!

Background: Venoarterial extra corporeal life support (ECLS) is the treatment of choice of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) class 1 patients, but left ventricle (LV) overload is a complication of ECLS. Unloading the LV by adding Impella 5.0 to ECLS in Impella used in combination with venoarterial extracorporeal membrane oxygenation (ECMELLA) configuration is recommended only in patients with acceptable prognosis. We investigated whether serum lactate level, a simple biological parameter, could be used as a marker to select candidates for bridging from ECLS to ECMELLA. Methods: Forty-one consecutive INTERMACS 1 patients under ECLS were upgraded to ECMELLA using Impella 5.0 pump implantation to unload the LV and were followed-up for 30 days. Demographic, clinical, imaging, and biological parameters were collected. Results: The time between ECLS and Impella 5.0 pump implantation was 9 [0-30] hours. Among these 41 patients, 25 died 6±6 days after implantation. They were older (53±12 vs. 43±12 years, P=0.01) with acute coronary syndrome as the primary etiology (64% vs. 13%, P=0.0007). In univariate analysis, patients who died exhibited a lower mean arterial pressure (74±17 vs. 89±9 mmHg, P=0.01), a higher level of troponin (24,000±38,000 vs. 3,500±5,000 mg/dL, P=0.048), a higher level of serum lactate (8.3±7.4 vs. 4.2±3.8 mmol/L, P=0.05) and more frequent cardiac arrest at admission (80% vs. 25%, P=0.03). In multivariate Cox regression analysis, a serum lactate level of >7.9 mmol/L (P=0.008) was found to be an independent predictor of mortality. Conclusions: In INTERMACS 1 patients who require urgent ECLS for restoring hemodynamics and organ perfusion, an upgrade from ECLS to ECMELLA is relevant if the serum lactate level is ≤7.9 mmol/L.

Transportation of patients under extracorporeal membrane oxygenation support on an airliner: Flying bridge to transplantation.

BACKGROUND: A retrieval programme was developed in Martinique (French West Indies) to provide extracorporeal membrane oxygenation for patients in the Caribbean, where heart transplantation and ventricular assist devices are not available. In 2011, the Department of Cardiac Surgery at the University Hospital of Fort-de-France (Martinique) developed a transfer programme to Paris (France) on an airliner, to refer patients for whom extracorporeal membrane oxygenation was not weanable to heart transplantation or a ventricular assist device. AIM: To report this unique experience of transportation of patients under extracorporeal membrane oxygenation support on an airliner from the French West Indies to Paris. METHODS: This was an observational and retrospective study of all patients under extracorporeal membrane oxygenation support who were transferred from Martinique to the Pitié-Salpêtrière Hospital/Sorbonne University in Paris between September 2011 and September 2019. Transport characteristics, complications during repatriation, cost and clinical outcomes at 30days and 1year were reported. RESULTS: Twenty-six patients were transferred on an airliner; the retrieval distance was 7260km, and the mean duration was 14hours. Only two patients developed complications (pulmonary oedema and leg ischaemia), and no patient died during the flight. Nine patients had a ventricular assist device implanted, and six patients were transplanted. Thirty-day survival was 65.4%, and 1-year survival was 38.5%. CONCLUSIONS: Transport under extracorporeal membrane oxygenation support on an airliner is safe and efficient, with an acceptable cost. This programme allowed patients under extracorporeal membrane oxygenation support in a remote centre, without access to transplantation or a ventricular assist device, to be referred for these techniques in specialized centres. This experience strengthens the strategy of developing regional networks around specialized extracorporeal membrane oxygenation centres.

Left ventricular functional improvement appears to contribute to lower rates of device thrombosis in patients on durable mechanical circulatory support.

By unloading the failing heart, left ventricular (LV) assist devices (LVADs) provide a favorable environment for reversing adverse structural and functional cardiac changes. Prior reports have suggested that an improved native LV function might contribute to the development of LVAD thrombosis. We used the Interagency Registry for Mechanically Assisted Circulatory Support and found that LV functional improvement is associated with a lower risk for device thrombosis. The risk for cerebrovascular accident and transient ischemic attack was comparable across post-LVAD LV function subgroups, while the risk of hemolysis was lower in subgroups of patients with better LV function on LVAD support.

Impact of mobilization in patients with short-term mechanical circulatory support such as Levitronix® CentriMag as a bridge to heart transplantation.

INTRODUCTION: Despite the benefits of mobilisation in the critical patient, the evidence in patients with Levitronix® CentriMag as a bridge to heart transplantation (HT) is scarce. The objective of this study is to analyze the impact of mobility on these patients. METHODS: Retrospective observational study of patients who received a HT with Levitronix® CentriMag admitted between 2010 and 2019 to a tertiary hospital. Degree of mobility and nutritional status were assessed at the time of HT. Outcomes including infections, length of hospital admission and mortality were evaluated. RESULTS: 27 patients were included and divided in two groups according to degree of mobility (22 with low mobility and 5 with high mobility). 90-day survival after HT was 63.6% in patients with low mobility and 80% in high mobility group; no statistically significant differences were observed. No differences were observed regarding ICU discharge after HT at 30 days. Nevertheless, lower albumin levels were observed in low mobility group (24,5 g/L (IQR: 23-30) vs 33 g/L (IQR: 26-36); p = .029). Invasive mechanical ventilation (IMV) post HT was longer in patients with low mobility (p = .014). There were no significant differences in appearance of pressure ulcers, or post HT infections among mobility groups. CONCLUSIONS: Patients with high mobility had a shorter time of IMV and a better nutritional status. No complications were observed associated to mobility. No differences were observed between the degree of mobility and 90-day mortality, ICU stay or post HT adverse events.

Impacto de la movilización en pacientes portadores de soporte circulatorio mecánico de corta duración tipo Levitronix® CentriMag como puente a trasplante cardíaco / Impact of mobilization in patients with short-term mechanical circulatory support such as Levitronix® CentriMag as a bridge to heart transplantation

Introducción: Pese a los beneficios de la movilización en el paciente crítico, la evidencia de su aplicación en pacientes portadores de Levitronix® CentriMag como puente a trasplante cardíaco (TC) es prácticamente nula. El objetivo del estudio fue analizar el impacto de la movilidad en estos pacientes. Métodos: Estudio observacional retrospectivo. Se incluyeron los pacientes sometidos a un TC previamente portadores de Levitronix® CentriMag ingresados entre el 2010 y el 2019 en el Hospital Universitario de Bellvitge. Se relacionaron las variables grado de movilidad y estado nutricional con la evolución clínica posterior al TC (infecciones, tiempo de estancia en UCI y mortalidad). Resultados: Los 27 pacientes seleccionados se dividieron en dos grupos según el grado de movilidad (22 baja y 5 alta). Se observó una supervivencia a 90 días post-TC del 63,6% en el grupo de pacientes con movilidad baja, mientras que en el grupo con movilidad alta fue del 80%; no se observaron diferencias estadísticamente significativas. Tampoco las hubo en la distribución de las altas de UCI desde el TC a 30 días. Por otro lado, se observaron unos menores niveles de albúmina en el grupo de movilidad baja, con una diferencia estadísticamente significativa (24,5 g/L [RIC: 23-30] vs. 33 g/L [RIC: 26-36]; p = 0,029). También se observaron diferencias en la mediana de días de ventilación mecánica invasiva (VMI) post-TC (p = 0,014), siendo mayor en el grupo de movilidad baja. No se observaron diferencias en la aparición de infecciones ni UPP. Conclusiones: Los pacientes con un grado de movilidad alto presentaron un menor tiempo de VMI y un mejor estado nutricional. No se observaron complicaciones asociadas a la movilidad. No se encontraron diferencias significativas entre el grado de movilidad y la mortalidad a 90 días, el tiempo de ingreso en UCI, la aparición de infecciones o UPP post-TC.(AU)

Introduction: Despite the benefits of mobilization in the critical patient, the evidence in patients with Levitronix® CentriMag as a bridge to heart transplantation (HT) is almost absent. The objective of this study is to analyze the impact of mobility on these patients. Methods: Retrospective observational study of patients who received a HT with Levitronix® CentriMag admitted between 2010 and 2019 to “Hospital Universitario de Bellvitge” (Barcelona). Degree of mobility and nutritional status were assessed at the time of HT. Outcomes including infections, length of hospital admission and mortality were evaluated. Results: 27 patients were included and divided in two groups according to degree of mobility (22 with low mobility and 5 with high mobility). 90-day survival after HT was 63.6% in patients with low mobility and 80% in high mobility group; no statistically significant differences were observed. No differences were observed regarding ICU discharge after HT at 30 days. Nevertheless, lower albumin levels were observed in low mobility group (24.5 g/L (IQR: 23-30) vs. 33 g/L (IQR: 26-36); p = 0.029). Invasive mechanical ventilation (IMV) post HT was longer in patients with low mobility (p = 0.014). There were no significant differences in appearance of pressure ulcers, or post-HT infections among mobility groups. Conclusions: Patients with high mobility had a shorter time of IMV and a better nutritional status. No complications were observed associated to mobility. No differences were observed between the degree of mobility and 90-day mortality, ICU stay or post-HT adverse events.(AU)

Prevalence of One-Year Mortality after Implantable Cardioverter Defibrillator Placement: An Opportunity for Palliative Care?

Background: Current guidelines recommend against placement of implantable cardioverter defibrillators in patients with a life expectancy less than one year. These patients may benefit from early palliative care services; however, identifying this population is challenging. Objective: Determine whether a validated prognostic tool, based on patient factors and health care utilization from electronic medical records, accurately predicts one-year mortality at the time of implantable cardioverter defibrillator placement. Design: We used the United States (U.S.) Veterans Administration's "Care Assessment Needs" one-Year Mortality Score to identify patients at high risk of mortality (score ≥95) before their procedure. Data were extracted from the Corporate Data Warehouse. Logistic regression was used to assess the odds of mortality at different score levels. Setting/Subjects: Patients undergoing a new implantable cardioverter defibrillator procedure between October 1, 2015 and September 30, 2017 in the U.S. Veterans Administration. Results: Of 3194 patients with a new implantable cardioverter defibrillator placed, 657 (21.8%) had a score ≥95. The mortality rate among these patients was 151/657 (22.9%) compared with 281/3194 (8.8%) for all patients undergoing a new implantable cardioverter defibrillator procedure. Patients with a score ≥95 had 14.0 (95% confidence interval 8.0-24.4) higher odds of death within one year of the procedure compared with those with a score ≤60. Conclusions: The "Care Assessment Needs" Score is a valid predictor of one-year mortality following implantable cardioverter defibrillator procedures. Integrating its use into the management of Veterans Administration (VA) patients considering implantable cardioverter defibrillators may improve shared decision making and engagement with palliative care.

Evaluation of Thrombocytopenia in Patients Receiving Percutaneous Mechanical Circulatory Support With an Impella Device.

Evaluate the time course of thrombocytopenia in patients with Impella devices (Abiomed, Danvers, MA). DESIGN: This was a retrospective, multicenter review of electronic medical records at a large hospital system from April 2018 to August 2020. SETTING: Electronic medical records of patients at SSM Health hospitals were reviewed. PATIENTS: Patients 18-89 years old admitted to an SSM Health hospital from April 2018 to August 2020 who received greater than or equal to 24 hours of percutaneous mechanical circulatory support (pMCS) with an Impella device were included. Exclusion criteria were use of other pMCS devices, history of heparin-induced thrombocytopenia (HIT), and presence of device upon transfer from an outside hospital. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ninety-three patients were included. The median duration of pMCS was 63.5 hours. Thrombocytopenia occurred in 86% of patients and was evident 24 hours after device placement. The platelet nadir occurred 84 hours after device placement. Platelet recovery occurred 86.5 hours after device removal. The duration of thrombocytopenia was 156 hours. Signs of hemolysis were present in 44.09% of patients, were evident 12-24 hours after device placement, and resolved after device removal. CONCLUSIONS: Thrombocytopenia occurred in the majority of patients and was evident 24 hours after device placement. The time course of thrombocytopenia mirrored that of hemolysis.

Percutaneous approach to left ventricular assist device decommissioning.

OBJECTIVE: To assess the outcomes of a single-center experience with percutaneous left ventricular assist device (LVAD) decommissioning. BACKGROUND: Patients with LVADs may eventually require their removal, either due to recovery of left ventricular function or recurrent complications. Traditionally, withdrawal of LVAD support has been managed with surgical device explantation, which carries significant procedural risks. Transcatheter LVAD decommissioning, with outflow graft occlusion and driveline transection, has recently been described as an alternative to surgical removal. METHODS: Here, we report on a retrospective cohort of five consecutive cases treated with transcatheter LVAD decommissioning. RESULTS: The procedure was effective in all cases, and no patient experienced procedure-related complications. At midterm follow-up, the three patients who had myocardial function recovery were alive and had not experienced heart failure-related symptoms or complications. CONCLUSION: Percutaneous LVAD decommissioning appears to be a safe and effective approach to LVAD treatment discontinuation.

Stress and Coping Among Family Caregivers of Patients With a Destination Therapy Left Ventricular Assist Device: A Multicenter Mixed Methods Study.

BACKGROUND: Family caregivers of patients with a destination therapy left ventricular assist device play a central and formalized role in postimplant care. We aimed to characterize longitudinal stress, predictors and correlates of stress, and coping processes among left ventricular assist device caregivers. METHODS: We performed a sequential, exploratory, mixed-methods study from 6 diverse left ventricular assist device programs. The primary outcome for the quantitative analysis was the Perceived Stress Scale-10 at 6 months (0-40). Based on the quantitative findings and guided by the Transactional Model of Stress and Coping, semistructured interviews explored causes of stress and coping processes. Integration was performed during the qualitative and interpretation phase. RESULTS: A total of 96 caregivers met inclusion criteria for quantitative analysis. Mean (SD) Perceived Stress Scale score was 14.3 (5.5) preimplant and 11.8 (6.9) at 6 months. Preimplant, only decreased preparedness for caregiving was associated with higher Perceived Stress Scale score at 6 months. At 6 months, increased caregiver depressive symptoms, decreased caregiver preparedness for caregiving, and lower patient quality of life were associated with higher Perceived Stress Scale score. Qualitative analysis of 25 caregivers revealed the causes of stress coalesced around 3 themes: (1) lack of preparedness to be a caregiver, (2) uniqueness of stress for the caregiver and patient situation, and (3) caregiving responsibilities physically and emotionally impacting caregivers. To cope with stress, most caregivers employed emotion-focused coping. CONCLUSIONS: In family caregivers of patients with a left ventricular assist device, higher perceived stress was associated with lower caregiver preparedness, higher caregiver depressive symptoms, and lower patient quality of life. Emotion-focused coping strategies were common for caregivers. Future work should better prepare caregivers for this role and support them through the caregiving experience. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02344576.

A picture is worth a thousand words: exploring the roles of caregivers and the home environment of ventricular assist device patients.

AIMS: Caregivers of persons living with ventricular assist devices (VADs) are integrally involved in both medical and non-medical care. We sought to understand tasks caregivers perform after surgical recovery, ways the home is adapted for those tasks, and presence of home safety hazards. METHODS AND RESULTS: We conducted semi-structured interviews with persons living with a VAD and their caregivers. Pictures were taken of areas in the home where: (i) caregiving activities occurred, (ii) VAD or medical supplies were kept, and (iii) home adaptations were made for VAD care. Pictures were described in written detail and analysed. A qualitative descriptive approach was used for analysis. The sample consisted of 10 dyads, with mostly spousal relationships (60%) between male patients (60%) and female caregivers (80%). Three themes were identified: (i) Evolution of Caregiving and Support: Patients gain independence, but caregivers are still needed, (ii) Adapting the Home Environment: Changes are focused on functional needs, and (iii) Hidden Dangers: Illumination of safety concerns by photographs. Assistance with bathing, driveline care, and medication management were common caregiving tasks. Most home adaptations occurred in the bathroom and bedroom including sleeping recliners, shower chairs, removable shower heads, and hanging hooks to hold VAD equipment. Safety hazards included minimal space for safe ambulation, infection risk, and home-made adaptations to the environment. CONCLUSIONS: These findings describe key home caregiving tasks, home adaptations, and safety concerns that require further education and support. Utilizing pictures may be a feasible method for assessing VAD teaching, caregiving needs, and identifying potential risks.