Faculty Bibliography

OBJECTIVES/OBJECTIVE:To understand how patients make decisions regarding a left ventricular assist device (LVAD). DESIGN/METHODS:A qualitative multiple case study design was used to explore the context and influence of individuals regarding patients' decision-making processes through: 1) detailed, in-depth interviews of those mostly involved in the patient's decision and 2) pertinent data including observations, medical records, educational information and physical artifacts. Data clusters and patterns of co-occurring codes were examined using thematic analysis. MAIN OUTCOME MEASURES/METHODS:Themes were extrapolated from individual case summaries to provide an in-depth analysis of each case and a cross-case analysis across the multiple cases. The predominant theme, consistent with other studies, was the salience of survival. FINDINGS/RESULTS:This case study approach revealed new themes beyond those of prior studies. Patients considered: 1) self-care management for patients without a caregiver, 2) acceptability and future expectations of the LVAD and 3) the role of nurses in eliciting patients' fears, values and preferences. CONCLUSION/CONCLUSIONS:The patients' decision-making processes regarding an LVAD involve a cost-benefit analysis of the anticipated needs and consequences of the LVAD. Acceptability of the device is relevant to clinical practice and public policy. Nurses have a unique role in seeking patients' concerns, an essential component of shared decision-making.

Purpose: The opioid epidemic has expanded the cardiac donor pool, but the concern for primary graft dysfunction (PGD) remains a barrier to wider utilization of these hearts. We analyzed donor characteristics in transplanted and discarded cardiac allografts from overdosed donors (ODD) to determine if viable ODD hearts are being unnecessarily discarded due to inappropriate bias. Method(s): Data on adult cardiac transplantation from 2010-2017 were provided by the SRTR. Eight donor characteristics associated with PGD were analyzed: age, gender, hypertension, high creatinine, cocaine abuse, inotropic support, LVEF, and cardiac arrest. Donor characteristics of transplanted and discarded hearts were compared between ODD and non-ODD. Result(s): ODD comprised 11% (1710/15904) of transplanted hearts and 7% (2600/32678) of discarded hearts. Among transplanted hearts, ODD more frequently were younger than 50 (98% vs 90%), did not have hypertension (86% vs 83%), and did not require inotropic support (62% vs 55%) compared to non-ODD; ODD less frequently were male (63% vs 70%), had no history of cocaine abuse (57% vs 84%), or had creatinine <=1.5 (62% vs 81%). Among discarded hearts, ODD more frequently were younger than 50 (87% vs 46%), had no history of hypertension (78% vs 49%), and did not require inotropic support (51% vs 41%); ODD less often had no history of cocaine abuse (50% vs 86%) or creatinine <=1.5 (61% vs 69%) (Table). Donors known to have at least 6 of 8 favorable qualities comprised 36% (942/2600) of discarded ODD hearts, compared to 28% (9152/32678) of discarded non-ODD hearts (p<0.001). The most common reasons given for discard of ODD hearts with favorable qualities were poor organ function (18%), refusal by all programs (16%), and lack of recipient (11%). Conclusion(s): ODD hearts with favorable qualities are being discarded at disproportionally higher rates than non-ODD hearts. Further studies and better documentation are needed to understand current discard practices and if further expansion into this donor pool is appropriate.

Purpose: Heart transplantation (HTx) from hepatitis C virus (HCV) positive donors to HCV negative recipients may reduce waitlist time and increase access to viable organs. Direct acting antivirals (DAAs) are highly successful at curing HCV infection, but the effect of DAAs on the pharmacokinetics of calcineurin inhibitors is largely unknown. We describe the effect on tacrolimus dosage requirements in recipients of HCV viremic donors. Method(s): We retrospectively reviewed HCV negative HTx patients who received a HCV positive organ. All patients received an 8 week course of glecaprevir-pibrentasvir (GP) for HCV treatment and were on standard triple immunosuppression therapy. Patients receiving concomitant medications that affect tacrolimus metabolism were excluded. All tacrolimus dosages and trough levels were collected from the time of initiation post-HTx until 1 month after completion of GP treatment. Tacrolimus dose normalized concentrations using the concentration:dose ration (ng/mL:mg/kg) were compared before, during, and after GP treatment. Result(s): Seven HTx recipients were included in the analysis. Tacrolimus dose normalized concentrations were 124.8, 163.4, and 196.7 (ng/mL)/(mg/kg/d) before, during and after GP treatment, respectively (Figure 1). Tacrolimus dosage requirements did not differ during GP treatment as compared to before or after GP treatment. The percentage of tacrolimus trough levels within goal range and the incidence of supratherapeutic tacrolimus levels, was 51% vs. 41% and 4% vs. 0% during GP treatment as compared to after GP treatment. Conclusion(s): We did not find a difference in tacrolimus dosage requirements while receiving GP treatment as compared to before or after GP treatment; however, this study was limited by a small sample size. No empiric dosage adjustments can be recommended when initiating or discontinuing GP treatment at this time. Further data will be needed to strengthen these findings.

Introduction: Cardiogenic shock is associated with high in-hospital mortality rates regardless of etiology. Recently, there has been an increase in utilization of acute mechanical circulatory support (MCS) in patients with cardiogenic shock. Although there is no consensus as to the most appropriate device for any particular patient presentation, acute MCS devices have been widely adopted in institutions that favor an aggressive approach to cardiogenic shock. Establishment of an Adult ECMO Program at our institution has led to experience with additional acute MCS devices. The complexity of these clinical situations led to the creation of a multidisciplinary team, including a combination of cardiologists, surgeons, interventionalists, and intensivists, committed to treating these patients. As an early ECMO Program and Cardiogenic Shock Team, we sought to review our early experience with acute MCS for cardiogenic shock to define our baseline strategies and outcomes in this patient population. Materials and Methods: We completed a retrospective review of cardiogenic shock patients who were treated with acute MCS by Fiscal Year (September 1 to August 31) beginning with Fiscal Year (FY) 2014. We reviewed implant volume by device, including temporary surgical ventricular assist device (VAD), percutaneous and surgical Impella, percutaneous RVADs, and veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO). Data collected included etiology of shock, indication for device implantation, type of support offered, length of support, and outcome of support. For each category of device, we also reviewed our outcomes by mirroring the established ELSO benchmarks of "Survival from ECMO" and "Survival to Discharge." Results: We found a steady increase in the use of acute MCS for treatment of cardiogenic shock from FY 2014 to FY 2018. From FY 2014 to 2015 there was an increase from zero to 18 implants. The following year (FY 2016) revealed a 100% increase, with a total of 36 implants. The volume increased more slowly (16%/year) the following two years (FY 2017, FY 2018) with 43 and 48 implants, respectively. Overall outcome assessment revealed that 68% of patients survived acute MCS and 53% of patients survived to hospital discharge with an increased survival to discharge in the last fiscal year to 62%. Conclusion: Creation of an Adult ECMO Program and a multidisciplinary Cardiogenic Shock Team correlated with an increase in the number of patients supported with acute MCS. As the team gains experience with these patients and the devices available to support them, we expect the outcomes to continue to improve. Patient selection, surgical approaches and techniques, standardizing medical therapy, and managing and reducing complications will give these patients the best opportunity to survive