Sunday, August 15, 2010

Holiday Heart

Going through training at the University of Minnesota, I think I had more exposure to left ventricular assist devices (LVADs) than the average internal medicine resident in the U.S.  Our university had (and continues to have) a very active program, and I remember the conference they had the interns attend to learn what to do and what not to do with LVADs. 

What NOT to do:
Don't remove both battery packs at the same time.
Don't let the driveline get infected.  
Don't do chest compressions, or you'll dislodge the tubes.

What to do:
If their heart stops, use the hand pump instead of chest compressions.
Call the VAD team if you have any problems.

At this point, I think my eyes were as big as saucers, knowing that as one of the "black cloud" interns that I could soon be dealing with problematic drivelines and trying to figure out how to hand pump someone's heart.

 When the nurse on the team who did LVADs, RVADs, and BiVADs (you guessed it, right ventricular assist devices and biventricular assist devices) brought out the box full of different LVADs, I remember thinking, "Someone went to Home Depot and got creative."  I have to admit, the whole "dislodge the tubes" thing, had me freaked out, but thankfully, the team that took care of the VAD patients was intensely involved. 

At the time, LVADs were used only as a bridge to heart transplant.  Now, LVAD technology has been significantly improved, the new devices are smaller, quieter, and the flow is continuous.  The new ones last longer without breaking down, have a longer battery life, and some don't have hand pumps.  Patients fare better with the newer ones too.  As discussed in Drew's post last year, the continuous flow LVADs improve quality of life for select end-stage heart failure patients who who are not eligible for heart transplant.  Referred to as "destination therapy," it is not exactly a tropical island, but it can be a true vacation from the symptoms and the poor functional status of end-stage heart failure.  

But, like all vacations, you have to pay for the trip. According to a piece by Minnesota Public Radio, the cost of implanting a LVAD runs between $150-$200K, but is covered by most insurances.  That isn't spare change, but we have lots of other expensive therapies for cancer, renal failure, etc., which may not give us as much bang for our buck.  After implantation, there is risk of stroke, bleeding, infection, kidney failure, and device failure.  If the device gets a serious infection or fails, you have to replace it.  If that isn't possible, the patient dies.  That's not the only cost, as you have to adjust your life to living with such a device, not only the medical and physical requirements, but the emotional, social, and spiritual aspects as well.  Still, many feel that the benefit outweighs the burden.  See the NY Times story on a man who accidently left his spare batteries at home, or watch the video of a woman awaiting transplant who goes camping and rides a bike after her LVAD placement.

At some point, however, the holiday comes to an end.  For those with a destination LVAD, it can extend life for 2-5 years, and for some even longer.  The 1-year survival  for the Thoratec Heartmate II destination LVAD is 68%, 2-year survival is 58%, as reported last year in NEJM.  On the flip-side, that means that almost one-third of patients die in the first year, and 42% of people die within two years.  Some patients or their surrogates even choose to withdraw LVAD support as reviewed in a recent Mayo Clinic Proceedings article and discussed in a WSJ health blog post

Still, even before the newest, improved versions of LVADs, the REMATCH trial (enrolling from 1998-2001) showed clear benefit in 1-year mortality, 52% for those with LVADs vs. 25% for optimal medical management.  Despite a significantly higher risk of adverse events with VADs, patients reported higher quality of life with the machines.  So... one could conclude that the LVAD is a palliative device of great significance for heart failure patients.

So... what's a hospice and palliative medicine physician to do?

We need to be proactive in collaborating with our cardiology and cardiothoracic surgery colleagues for this special group of people.
  • We need to promote the discussion about what a patient would want post-implantation in particular circumstances prior to the actual surgery.  
  • We need to educate ourselves about LVADs and work closely with our colleagues.  They are still end-stage heart failure patients; they just have some really fancy equipment.
  • We need to be able to anticipate how these people may die, and prevent and/or palliate the symptoms they may have in the process.  (Anyone already doing palliative medicine data collection with these patients?)
  • We need to make sure that our palliative medicine teams and our hospices are prepared to help this special group of patients live well, and when the time comes, die as peacefully as possible. 
  • We may even help identify patients that may benefit from LVAD implantation and refer them to centers that place them, if it is consistent with their goals of care.
With Dick Cheney being arguably the most famous person to get an LVAD, the devices have gotten a huge bump in media attention.  The number of patients receiving a LVAD as a bridge to transplant or as destination therapy will only increase as the technology continues to improve and patients learn to advocate for them.  LVADs aren't for everyone, and they aren't without significant personal and financial cost, but they will be an option for more and more patients, potentially extending prognosis for years and improving quality of life. 

Now, if only we could get them to go solar...

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