Marie Galvao1, Omar Saeed2, Jason Immekus3, Daniel J Goldstein4, Simon Maybaum5. 1. Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. Electronic address: mgalvao@montefiore.org. 2. Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. 3. Department of Educational Leadership and Human Resource Education, University of Louisville, Louisville, Kentucky. 4. Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York. 5. US Medical,Critical Care, Novartis Pharmaceutical, East Hanover, New Jersey.
Abstract
BACKGROUND: Criteria for the identification of patients who may progress to advanced heart failure (HF) have been previously suggested. However, identification of appropriate non-inotrope-dependent (NID) patients for destination therapy (DT) remains a challenge, and referral rates are low. We surveyed expert provider opinion about patient selection for early DT. METHODS: An internet-based survey was sent to international HF providers to investigate opinions about clinical indicators for referral of NID patients for DT. Subjects were identified from membership lists of HF professional organizations. Respondents provided their level of agreement with the use of a 5-point Likert Scale (1 = strongly disagree to 5 = strongly agree) to 10 clinical criteria describing at-risk NID patients. RESULTS: A total of 231 respondents who had been in a position to recommend left ventricular assist device (LVAD) therapy for 7.6 ± 5.8 years identified themselves as HF providers: 41% HF cardiologists, 27% HF nurse practitioners, 21% cardiothoracic surgeons, 9% LVAD coordinators, and 2% general cardiologists. More than two-thirds of the respondents agreed or strongly agreed with 7 of the 10 items. Similar consensus was not seen for 6-minute walk (6MW) or B-type natriuretic peptide (BNP). When asked which criteria would have to be present for LVAD referral, only hemodynamic deterioration reached ≥50% affirmation among respondents. No criteria reached >50% response as being sufficient alone for DT. CONCLUSION: We describe referral thresholds for early LVAD therapy among international HF providers. With the exception of BNP and 6MW, we found overall agreement on the proposed clinical parameters. Despite apparent consensus, in practice implantation rates for LVAD in NID patients remain low. The results of ongoing clinical trials in this population may lower thresholds for early referral for DT.
BACKGROUND: Criteria for the identification of patients who may progress to advanced heart failure (HF) have been previously suggested. However, identification of appropriate non-inotrope-dependent (NID) patients for destination therapy (DT) remains a challenge, and referral rates are low. We surveyed expert provider opinion about patient selection for early DT. METHODS: An internet-based survey was sent to international HF providers to investigate opinions about clinical indicators for referral of NIDpatients for DT. Subjects were identified from membership lists of HF professional organizations. Respondents provided their level of agreement with the use of a 5-point Likert Scale (1 = strongly disagree to 5 = strongly agree) to 10 clinical criteria describing at-risk NIDpatients. RESULTS: A total of 231 respondents who had been in a position to recommend left ventricular assist device (LVAD) therapy for 7.6 ± 5.8 years identified themselves as HF providers: 41% HF cardiologists, 27% HF nurse practitioners, 21% cardiothoracic surgeons, 9% LVAD coordinators, and 2% general cardiologists. More than two-thirds of the respondents agreed or strongly agreed with 7 of the 10 items. Similar consensus was not seen for 6-minute walk (6MW) or B-type natriuretic peptide (BNP). When asked which criteria would have to be present for LVAD referral, only hemodynamic deterioration reached ≥50% affirmation among respondents. No criteria reached >50% response as being sufficient alone for DT. CONCLUSION: We describe referral thresholds for early LVAD therapy among international HF providers. With the exception of BNP and 6MW, we found overall agreement on the proposed clinical parameters. Despite apparent consensus, in practice implantation rates for LVAD in NIDpatients remain low. The results of ongoing clinical trials in this population may lower thresholds for early referral for DT.
Authors: Thomas Puehler; Stephan Ensminger; Michael Schoenbrodt; Jochen Börgermann; Erik Rehn; Kavous Hakim-Meibodi; Michiel Morshuis; Jan Gummert Journal: Ann Cardiothorac Surg Date: 2014-09