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Choices: a study of preferences for end-of-life treatments in patients with advanced heart failure.

https://arctichealth.org/en/permalink/ahliterature155363
Source
J Heart Lung Transplant. 2008 Sep;27(9):1002-7
Publication Type
Article
Date
Sep-2008
Author
Jane MacIver
Vivek Rao
Diego H Delgado
Nimesh Desai
Joan Ivanov
Susan Abbey
Heather J Ross
Author Affiliation
Division of Cardiology, Peter Munk Cardiac Center, Toronto General Hospital, Toronto, Ontario, Canada.
Source
J Heart Lung Transplant. 2008 Sep;27(9):1002-7
Date
Sep-2008
Language
English
Publication Type
Article
Keywords
Adult
Advance Care Planning - statistics & numerical data
Aged
Attitude to Health
Cardiotonic Agents - therapeutic use
Choice Behavior
Defibrillators, Implantable
Dyspnea
Fatigue
Female
Heart Failure - drug therapy - psychology - therapy
Heart-Assist Devices
Humans
Male
Middle Aged
Ontario
Quality of Life
Questionnaires
Severity of Illness Index
Young Adult
Abstract
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.
PubMed ID
18765193 View in PubMed
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Donor management in cardiac transplantation.

https://arctichealth.org/en/permalink/ahliterature187511
Source
Can J Cardiol. 2002 Nov;18(11):1217-23
Publication Type
Article
Date
Nov-2002
Author
Diego H Delgado
Vivek Rao
Heather J Ross
Author Affiliation
Toronto General Hospital, University of Toronto, Toronto, Canada.
Source
Can J Cardiol. 2002 Nov;18(11):1217-23
Date
Nov-2002
Language
English
Publication Type
Article
Keywords
Brain Death - physiopathology
Canada
Heart Transplantation
Humans
Tissue Donors - statistics & numerical data
Tissue and Organ Procurement
Abstract
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.
PubMed ID
12464986 View in PubMed
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Effects of folic acid fortification and multivitamin therapy on homocysteine and vitamin B(12) status in cardiac transplant recipients.

https://arctichealth.org/en/permalink/ahliterature180780
Source
J Heart Lung Transplant. 2004 Apr;23(4):405-12
Publication Type
Article
Date
Apr-2004
Author
Santiago G Miriuka
Loralie J Langman
Eitan S Keren
Steven E S Miner
Orval A Mamer
Diego H Delgado
Jovan Evrovski
Heather J Ross
David E C Cole
Author Affiliation
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Source
J Heart Lung Transplant. 2004 Apr;23(4):405-12
Date
Apr-2004
Language
English
Publication Type
Article
Keywords
5-Methyltetrahydrofolate-Homocysteine S-Methyltransferase - genetics
Adult
Canada
Cohort Studies
Dietary Supplements
Female
Ferredoxin-NADP Reductase - genetics
Folic Acid - blood - therapeutic use
Food, Fortified
Heart Transplantation
Homocysteine - blood - drug effects - genetics
Humans
Hyperhomocysteinemia - blood - drug therapy
Male
Methylenetetrahydrofolate Reductase (NADPH2) - genetics
Methylmalonic Acid - blood
Middle Aged
Polymorphism, Single Nucleotide - genetics
Vitamin B 12 - blood
Vitamins - therapeutic use
Abstract
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.
PubMed ID
15063399 View in PubMed
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How aware of advanced care directives are heart failure patients, and are they using them?

https://arctichealth.org/en/permalink/ahliterature135036
Source
Can J Cardiol. 2011 May-Jun;27(3):376-81
Publication Type
Article
Author
Marlena V Habal
Vaska Micevski
Sarah Greenwood
Diego H Delgado
Heather J Ross
Author Affiliation
Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
Source
Can J Cardiol. 2011 May-Jun;27(3):376-81
Language
English
Publication Type
Article
Keywords
Adult
Advance Care Planning
Advance Directives
Aged
Attitude to Death
Cardiopulmonary Resuscitation - statistics & numerical data
Critical Illness - mortality
Cross-Sectional Studies
Decision Making
Defibrillators, Implantable - statistics & numerical data
Female
Health Knowledge, Attitudes, Practice
Heart Failure - diagnosis - mortality - therapy
Humans
Male
Middle Aged
Needs Assessment
Ontario
Physician-Patient Relations
Prospective Studies
Questionnaires
Severity of Illness Index
Young Adult
Abstract
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.
PubMed ID
21514785 View in PubMed
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Impact of fixed pulmonary hypertension on post-heart transplant outcomes in bridge-to-transplant patients.

https://arctichealth.org/en/permalink/ahliterature96392
Source
J Heart Lung Transplant. 2010 Jul 8;
Publication Type
Article
Date
Jul-8-2010
Author
Ana Carolina Alba
Vivek Rao
Heather J Ross
Annette S Jensen
Kaare Sander
Finn Gustafsson
Diego H Delgado
Author Affiliation
Division of Cardiology and Heart Transplantation, University Health Network, Toronto, Ontario, Canada.
Source
J Heart Lung Transplant. 2010 Jul 8;
Date
Jul-8-2010
Language
English
Publication Type
Article
Abstract
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
PubMed ID
20620083 View in PubMed
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Mechanical circulatory support as a bridge to transplant candidacy.

https://arctichealth.org/en/permalink/ahliterature131723
Source
J Card Surg. 2011 Sep;26(5):542-7
Publication Type
Article
Date
Sep-2011
Author
Abdelsalam M Elhenawy
Khaled D Algarni
Marnie Rodger
Jane Maciver
Manjula Maganti
Robert J Cusimano
Terrence M Yau
Diego H Delgado
Heather J Ross
Vivek Rao
Author Affiliation
Heart Transplant Program, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada.
Source
J Card Surg. 2011 Sep;26(5):542-7
Date
Sep-2011
Language
English
Publication Type
Article
Keywords
Female
Follow-Up Studies
Heart Failure - mortality - therapy
Heart Transplantation - methods - mortality
Heart-Assist Devices
Humans
Male
Middle Aged
Ontario - epidemiology
Patient Selection
Preoperative Care - methods
Retrospective Studies
Survival Rate - trends
Treatment Outcome
Abstract
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.
PubMed ID
21883463 View in PubMed
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Mechanical circulatory support with the ABIOMED BVS 5000: the Toronto General Hospital experience.

https://arctichealth.org/en/permalink/ahliterature139313
Source
Can J Cardiol. 2010 Nov;26(9):467-70
Publication Type
Article
Date
Nov-2010
Author
Vidyadhar Lad
Abdelsalam Elhenawy
Steve Harwood
Jane Maciver
Mitesh Vallabh Badiwala
Mark Vallelonga
Terrence M Yau
Robert J Cusimano
Diego H Delgado
Heather J Ross
Vivek Rao
Author Affiliation
Heart Transplant Program, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Ontario.
Source
Can J Cardiol. 2010 Nov;26(9):467-70
Date
Nov-2010
Language
English
Publication Type
Article
Keywords
Adult
Cardiac Surgical Procedures - instrumentation
Equipment Design
Female
Heart Failure - mortality - surgery
Heart Transplantation - instrumentation
Heart-Assist Devices - adverse effects
Hospital records
Hospitals, General
Humans
Male
Medical Records
Middle Aged
Ontario
Practice Guidelines as Topic
Retrospective Studies
Shock, Cardiogenic - mortality - surgery
Survival Analysis
Time Factors
Treatment Outcome
Abstract
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.
Notes
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PubMed ID
21076718 View in PubMed
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Mycophenolate mofetil dose reduction for gastrointestinal intolerance is associated with increased rates of rejection in heart transplant patients.

https://arctichealth.org/en/permalink/ahliterature159396
Source
J Heart Lung Transplant. 2008 Jan;27(1):72-7
Publication Type
Article
Date
Jan-2008
Author
Paul J Galiwango
Diego H Delgado
Raymond Yan
Stella Kozuszko
Robert Smith
Vivek Rao
Heather J Ross
Author Affiliation
Division of Cardiology, Toronto General Hospital, Toronto, Ontario, Canada. pgaliwango@utoronto.ca
Source
J Heart Lung Transplant. 2008 Jan;27(1):72-7
Date
Jan-2008
Language
English
Publication Type
Article
Keywords
Female
Follow-Up Studies
Gastrointestinal Diseases - chemically induced
Graft Rejection - drug therapy - epidemiology
Heart Transplantation
Humans
Immunosuppressive Agents - administration & dosage
Incidence
Male
Middle Aged
Mycophenolic Acid - administration & dosage - analogs & derivatives
Ontario - epidemiology
Prodrugs
Prognosis
Retrospective Studies
Risk factors
Abstract
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.
PubMed ID
18187090 View in PubMed
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8 records – page 1 of 1.