The purpose of this study is to describe the treatment preferences of patients with heart failure among three distinct treatment options--optimal medical management, oral inotropes or left ventricular device (LVAD) support--to determine if there were differences in preferences between patients with mild heart failure (New York Heart Association [NYHA] Class II) and severe heart failure (NYHA Class IV), and also to determine whether quality of life, perceived severity of symptoms and overall health influenced treatment preferences.
We enrolled 91 patients who completed the Minnesota Living with Heart Failure Questionnaire (MLHFQ); visual analog scales for depicting their perceived severity of overall health, dyspnea and fatigue; and a treatment trade-off tool.
The most preferred treatment options were oral inotropes, LVAD and standard medical management. There were no differences in treatment preferences between NYHA II and NYHA IV patients. Patient preferences correlated poorly with MLHFQ, symptom and overall health scores. Although not statistically significant, there was a trend toward patients with worse quality of life and symptom scores preferring more aggressive treatment.
The results of our study identified two distinct groups of patients: one group preferring treatments that prolonged survival time and another group that favored strategies that improved quality of life but reduced survival time. Treatment preferences were independent of functional or symptom status, suggesting that preferences may be decided early in the course of illness.
The most important limitation in organ transplantation is donor availability. Canada is facing a serious situation with respect to organ donation rates and transplantation. The number of patients listed for heart transplant continues to increase while the number of available donors has plateaued. Several steps can be taken to address this growing mismatch. The proper identification and assessment of potential donors together with improvements in medical management may increase the donor pool. Additionally, the use of marginal donors and the development of new organ preservation techniques may lead to an increase in the number of potential heart transplants in Canada. This paper summarizes the identification, evaluation and management of heart transplant donors, and defines strategies to improve procurement activity in heart transplantation.
Hyperhomocysteinemia is a frequent finding after cardiac transplantation, but increased folate intake induces a decrease in total homocysteine concentrations. In 1998, food in Canada was fortified nationwide with folic acid. We assessed the impact of routine folate fortification on homocysteine concentrations in our cardiac transplant population.
In 18 subjects, we measured total homocysteine (tHcy), serum folate, and cobalamin concentrations in 1997 (before folate fortification) and in 1998 (after fortification). We repeated the analysis after specific multivitamin supplementation for 10 weeks.
We found a significant decrease in baseline tHcy concentrations and in folate concentrations between 1997 and 1998. However, we also found a decrease in serum cobalamin concentrations. We found a correlation between decreased cobalamin concentrations and the methionine synthase A2756G genotype, but not with other common polymorphisms associated with homocysteine metabolism. After multivitamin supplementation, we observed a trend toward further decrease in tHcy concentrations and a significant increase in serum folate and cobalamin concentrations. Finally, we measured serum methylmalonic acid concentrations, an index of tissue cobalamin status. We did not find a correlation between increased methylmalonic acid concentrations and decreased serum cobalamin, perhaps related to the confounding effect of altered renal status on methylmalonic acid excretion.
National folate fortification was associated with decreased tHcy and increased folate concentrations in our cardiac transplant population. Additional administration of vitamin supplements induced a further decrease in tHcy and an increase in folate. Finally, folate fortification unveiled cobalamin deficiency in some patients, associated with the methionine synthase A2756G mutation.
The increasing prevalence of heart failure and its unpredictable trajectory highlight the need for patients to make their end-of-life care wishes known using advanced care directives (ACDs). The paucity of literature addressing heart failure patients' decision-making processes and knowledge of ACDs underscores the need for investigation. The purposes of this study were to (1) determine patients' awareness, comprehension, and utilization of ACDs and (2) determine their knowledge of the process of cardiopulmonary resuscitation and their current resuscitation preference.
A prospective, single-centre study was designed to collect quantitative data addressing patients' understanding of ACDs and cardiopulmonary resuscitation as well as their current resuscitation preference. Patients who consented were interviewed using a semistructured questionnaire. Data were analyzed using descriptive statistics.
Of the 41 participants, 76% did not know what ACDs were and fewer recalled discussing them with their physician. Nearly 80% of the 37 queried participants would have preferred to discuss ACDs. More than 75% of participants wanted full resuscitation if they were to require it at this time. Most participants had not documented their resuscitation preference, and only slightly over half said their substitute decision maker was aware of their preference. Among the 19 with an implantable cardioverter-defibrillator, nearly half would want it deactivated should their condition worsen. Only 2 participants recalled having discussed this option with their physician.
There remains a lack of knowledge and utilization of ACDs among this heart failure population. Participants' preferences highlight the importance of discussing ACDs and exploring resuscitation preferences early and often in heart failure.
BACKGROUND: Fixed pulmonary hypertension (FPH) is considered a contraindication to cardiac transplantation. Ventricular assist device (VAD) therapy through prolonged left ventricular unloading may reverse FPH. Our aim was to assess post-transplant outcomes and survival in patients with and without FPH undergoing VAD implantation as bridge to transplant. METHODS: Fifty-four patients received an intracorporeal left VAD (LVAD) as a bridge to transplant from 2000 to 2008 at two institutions (Rigshospitalet, Denmark, and the Toronto General Hospital, Canada). Twenty-two (41%) patients had fixed FPH (defined as pulmonary vascular resistance [PVR] >3 Wood units and resistant to pulmonary vasodilators) prior to VAD implant (FPH group) and were compared with 32 patients without FPH (NoFPH group). Baseline characteristics, pre- and post-transplant pulmonary pressures, incidence of complications and post-transplant survival were analyzed. RESULTS: Baseline characteristics were similar except that patients in the FPH group were older (46 +/- 11 years vs 39 +/- 13 years in the NoFPH group, p
The use of mechanical circulatory support (MCS) in nontransplant eligible candidates remains controversial. Our decision to offer MCS for nontransplant candidates has led to their reevaluation after a period of left ventricular assist device (LVAD) support.
From 2001 to September 2009, we had 37 patients who received an implantable LVAD, 22 (59%) were not deemed to be transplant eligible at the time of LVAD insertion (bridge to candidacy, BTC group).
Fifteen (41%) patients were considered transplant eligible (bridge to transplant, BTT group) at the time of device insertion and received a HeartMate XVE (n = 7), HeartMate 2 (n = 7), or a Novacor LVAS (n = 1). In the BTC group, patients received the HeartMate XVE device (n = 11), HeartMate 2 (n = 5), or the Novacor LVAS (n = 6). The primary criterion for transplant ineligibility was refractory pulmonary hypertension (PH) in 18 patients, 3 patients did not meet our body mass index criteria (>35 kg/m(2)), and 2 patients were dialysis-dependent. Six (27%) BTC patients died on support. Overall, 16/22 patients (73%) were subsequently listed for transplantation, with one listed for combined heart-lung due to refractory PH. Twelve patients (75%) underwent successful heart transplantation. Three patients died during their transplant. Overall posttransplant survival at one year shows lower survival in the BTC group compared to the BTT group (67% vs. 100%, p = 0.05). At two years and three years the survival was lower, but not statistically different (BTC vs. BTT: 67% vs. 90% and 64% vs. 87%, respectively, p = NS).
MCS can successfully convert a large proportion of transplant-ineligible patients into acceptable candidates.
Acute hemodynamic collapse resulting in cardiogenic shock and impending end-organ failure is usually associated with certain death. The introduction of short-term mechanical circulatory support (MCS) devices offers potential therapy to these critically ill patients. The BVS 5000 device (ABIOMED Inc, USA) is widely used in the United States, but rarely in Canada, where device reimbursement remains a barrier.
To present the Toronto General Hospital's (Toronto, Ontario) initial five-year experience with this device to highlight the indications for use, common complications and overall success rates.
The institutional MCS database from 2001 to 2006 was reviewed, and 18 patients who received 30 devices in a variety of configurations were identified. The most common support configuration consisted of biventricular support (n=12), followed by isolated left ventricular support (n=4) and isolated right ventricular support in two recipients of an implantable long-term left ventricular assist device. Overall survival to device explant or transplant was 55% (n=10), of which five (50%) were successfully discharged from the hospital. The overall survival from device implant to hospital discharge was 28% (five of 18). The most common cause of death was multisystem organ failure.
MCS with the ABIOMED BVS 5000 can successfully resuscitate critically ill patients; however, earlier institution of this device would avoid irreversible end-organ injury, and lead to higher rates of device explant and hospital discharge. Short-term MCS devices should be available in all cardiac surgical centres in Canada to permit stabilization and evaluation of the acutely ill cardiac patient and subsequent management in a heart transplant facility.
Cites: N Engl J Med. 2000 Mar 9;342(10):690-510706898
Cites: Ann Thorac Surg. 1999 Aug;68(2):678-8310475470
Cites: Perfusion. 2001 Jan;16(1):13-811192302
Cites: Ann Thorac Surg. 2001 Mar;71(3 Suppl):S67-72; discussion S82-511265869
Cites: Transplant Proc. 2001 Feb-Mar;33(1-2):1603-411267436
Cites: Ann Thorac Surg. 2001 May;71(5):1719-2011383845
Cites: Intensive Care Med. 2001 Aug;27(8):1321-711511945
Gastrointestinal (GI) intolerance to mycophenolate mofetil (MMF) is a frequent problem. We conducted a retrospective analysis of all the heart transplant patients followed up at the Toronto General Hospital from the years 1999 to 2006 to determine the impact of dose reductions for GI intolerance on rejection rates.
The charts of all patients followed up in the heart transplant clinic at the Toronto General Hospital from the years 1999 to 2006 were reviewed. Sustained significant rejection was defined as an International Society of Heart and Lung Transplantation grade 2 or higher on 2 successive biopsies. The Student's t-test was used to compare rates of rejection between populations.
Mycophenolate mofetil was part of the anti-rejection regimen in 182 of 189 patients (98%), and the medication dose in 71% of these patients had to be reduced at some point because of intolerance or toxicity. The prevalence of sustained significant rejection was significantly higher in the group of patients with GI intolerance to MMF compared with patients maintained on target doses (66% vs 35%, p = 0.002) or patients with non-GI related toxicities necessitating dose reduction (67% vs 35%, p = 0.003).
Gastrointestinal intolerance is a common reason for MMF dose reduction in heart transplant patients and was associated with a significantly increased rate of sustained rejection, suggesting that these individuals need to have particularly close follow-up.