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Care of patients with heart failure and the use of ventricular assist devices

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Mandy Hipkin, BSc (Hons), RGN.

Artificial Heart Nurse Specialist at the Royal Brompton and Harefield NHS Trust, Harefield, Middlesex

Chronic heart failure is a complex and debilitating condition that can be defined as an inability of the heart to support the physiological requirements of the body. Heart failure carries a greatly increased mortality risk that is often worse than most malignant diseases (Millane et al, 2000), with just under 40% of patients dying within one year of diagnosis (Peterson et al, 2002).

The incidence of heart failure is also rising, with some studies indicating as many as 10% of men over the age of 74 and between 10 and 13% of women in the same age group experiencing heart failure (Mair et al, 1996; Office for National Statistics, 2000). One study in the West Midlands (Davies et al, 2001) found the incidence of heart failure in the over-85 male group was in excess of 20%, indicating that the risk of heart failure also increases with age. The major cause of heart failure is coronary heart disease. However, a number of other diseases (valvular heart disease, cardiomyopathy and congenital heart disease) can also predispose the condition. The increased prevalence of heart failure can be partially attributed to the success of modern medical treatments and partly to an ageing population.

Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support physiological circulation. The syndrome of heart failure is characterised by symptoms such as breathlessness, fatigue and signs such as fluid retention. Team management of patients with heart failure is reported by Grady et al (2000) and also recommended by the National Institute for Clinical Excellence (NICE, 2003).

The majority of patients with chronic heart failure are managed using a combination of diuretic therapy, ACE inhibition and beta blockade. However, there are a number of patients for whom this type of drug therapy is unable to provide symptom control and whose condition is likely to rapidly deteriorate (DH, 2002). Some of these patients will require palliative care but others may benefit from a surgical approach.

Surgical approaches include:

- Insertion of ventricular assist devices

- Cardiac transplantation

- Bista procedure (left ventricle resection).

When heart failure becomes intractable and resistant to treatment, consideration is then given to cardiac transplantation. Not all patients, however, will survive the cardiac transplant waiting list because of a decline in transplantation rates mainly due to a shortage of suitable donor organs (Taylor et al, 2003). VAD support is indicated for patients with chronic heart failure whose haemodynamic status deteriorates despite maximal drug therapy and/or intra-aortic balloon pump assistance (Frazier et al, 2003).

Cardiac transplantation

Cardiac transplantation has become a very effective treatment for severe cardiac failure, with around two-thirds of patients living beyond five years following transplantation (Hosenpud et al, 2001). The availability of modern immuno-suppressive drugs has dramatically reduced the risk of rejection and therefore increased the likelihood of patients returning to a fuller life. However, the rates of cardiac transplantation have dramatically reduced over the past 10 years.

In 1995-96, 446 heart and heart-and-lung transplants were performed in the UK (DH, 2001); in 2000 it was 286 (see Figure 1). The Department of Health (DH, 2001) state that the ‘fall in the number of transplants is a direct result of fewer organs being available for transplantation’. This reduction in availability of suitable donors is possibly related to the fall in the number of fatal road accidents in the same period.

There is also a need to increase the rate of organ donation from specific minority groups. The success rate of a transplant is increased if both the donor and the recipient come from the same ethnic group. Yet while Asian people make up 4% of the UK population and 6% of the transplant recipient population, they form less than 2% of the donor population (DH, 2003). The reason for this reduced donor rate needs to be explored further. One hypothesis is that there may be a belief among non-Asian health-care staff that Asian patients are unable to donate organs on religious grounds and therefore do not broach the subject. However, none of the main religious faiths specify that transplantation or organ donation is unacceptable.

Ventricular assist devices (VADS)

Left ventricular assist device (VAD) insertion as a bridge until transplantation is usually considered either because of cardiogenic shock or secondary organ dysfunction, which are contraindications for transplantation (Birks et al, 2004).

A ventricular assist device is a mechanical pump that is surgically implanted. It assists the heart in pumping blood around the body by draining blood from one part of the heart, for example the left ventricle, and pumping the blood back into another part of the heart, for example the aorta, thus reducing the workload of the heart. The VAD provides specific benefits related to recovery of haemodynamic stability, and renal and hepatic function may be improved (Ashton et al, 1996), as may nutritional status (Nishimura et al, 1996). This improves the symptoms of end-stage heart failure, allowing patients to become mobile and be discharged into the community, while improving their quality of life. Mehta et al (1995) reported that patients in whom a left ventricular assist device (LVAD) was implanted as a bridge to transplant had a better outcome than medically managed patients waiting for transplantation, with 92% of LVAD patients living to receive transplants compared to 68% of medically managed patients.

Types of devices

There are three main types of device used (see box below):

- Vented electric left VAD placed in the abdomen (such as the Heartmate I)

- Paracorporeal (external) VAD (such as the Thoratec PVAD)

- Miniature left ventricle-sited VAD (such as the Jarvik 2000 Left Ventricular Assist Device).

Choosing a device

The choice of device is made by the consultant cardiac surgeon and depends on the size of the patient, ability of the patient to tolerate anti-coagulation, previous surgery (abdominal, cardiac), any abdominal problems and the type of support required, that is. left, right, long term or short term.

Care of the patient

Pre-implantation

Informed consent is obtained from the patient with the risks and benefits of the procedure explained in detail by cardiologist, surgeon and VAD personnel, such as postoperative bleeding, cardiovascular accident, infection and renal failure.

Patients and relatives anticipating implantation may fear it will result in a dependence on the device (and loss of independence), financial hardship, changes in body image, a loss of control and that he or she will become a burden to the family (McCafferty et al, 2002). It is critical that these issues are addressed before the implant is undertaken. The artificial heart nurse specialist takes an active role in supporting patients and carers to accept the ventricular assist device implant.

Post-implantation

Following the surgery the patient is nursed in the intensive care unit. Early extubation is encouraged and inotropic support is weaned as tolerated by the patient. Careful monitoring of haemodynamic, renal and hepatic status is necessary. Likewise, any signs of infection is noted and treated promptly.

The patient is transferred to a high-dependency area in the ward when all parameters are stable and an active approach to rehabilitation begins. Early ambulation is encouraged together with self-care. Nursing responsibilities include accurate monitoring of fluid balance, daily weight, four-hourly haemodynamic observations, assessment of wounds and maintenance of anticoagulation therapy.

Patient education is crucial to the success of coping with the device (Bond et al, 2003). As early as possible, patients and carers (usually family) are instructed in the operation and management of the device including:

- How to change the batteries

- Daily maintenance

- Alarm recognition

- Troubleshooting

- Emergency procedures, which include hand-pumping to maintain the function of the device in the case of mechanical failure.

The patient and carers must be able to carry out these procedures without hesitation. The educational plan must also include dressing techniques for the carers or district nurses. Infection around the exit (driveline) site is not uncommon (Holman et al, 2003). As the patient and his or her carer become more comfortable with the operation of the device stress and anxiety levels will decrease and the quality of life will improve (Grady et al, 2002). Within our trust we have a formal education package, which includes patients and carers completing a written quiz related to their specific device.

The discharge process includes five escorted visits with the artificial heart nurse specialist out of the hospital environment, starting with a walk to the local village and progressing to a shopping trip or meal in a nearby town. This helps patients and carers to gain confidence while rehabilitating their physical condition and prepares them for eventual discharge. Following the escorted visits the patients and carers complete five unescorted visits, returning to the hospital after each trip. We ensure that all patients have mobile telephones to enable them to contact the artificial heart team if required.

It is anticipated that, before hospital discharge, the patients have been formally assessed for transplantation and are added to the waiting list for cardiac transplant.

Community care

Before discharge the VAD team contact, visit and educate the patient’s local GP, practice nurses/district nurses, accident and emergency department staff, cardiology unit staff and ambulance personnel. This ensures that the patient is on their records as having an artificial heart, and as requiring special considerations or resuscitation, and that they have contact numbers for our VAD and medical team.

All patients have access to a 24-hour on-call service, provided by the artificial heart team. This enables rapid access to hospitalisation if necessary. Patients are seen in the heart failure/ heart transplant waiting list clinic monthly. Most patients have their anti-coagulation therapy managed at their local hospital.

Better treatment options

With an ageing population the incidence of heart failure is likely to increase further. In the past treatment options focused on drug therapy and cardiac transplantation. However, many patients die while waiting for a suitable donor organ to become available. The advent of ventricular assist devices has broadened treatment options for people with heart failure.

VADs are capable of not only stabilising the patient’s condition in the short term but patients who are transplanted following the insertion of a VAD have similar or better outcome to that of stable heart failure patients (DH, 2002). The use of VADs as a bridge to transplantation is rapidly becoming an accepted aspect of care, hence the development of specialist centres to cater for this need. Currently VADs are used predominantly for ‘bridge to transplant’ but it is possible that with an increase in technological competence they may eventually replace the need for transplantation altogether.

With increased numbers of VAD recipients, it is imperative that nurses are capable of providing and directing appropriate care and support to patients and their carers in a safe environment.

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NICE guidance on treatment of heart failure

- Diagnosis. A definite diagnosis of heart failure should be confirmed before NICE guidelines are put in place. An echocardiograph examination should be performed to exclude significant valve disease, assess the systolic and diastolic function of the left ventricle and detect intracardiac shunts

- Treatment. All patients with heart failure due to left ventricular systolic function should be considered for treatment with an ACE inhibitor. Beta blockers licensed for use in heart failure should be initiated in patients with heart failure due to ventricular systolic dysfunction after diuretic and ACE inhibitor therapy (regardless of whether or not symptoms persist)

- Lifestyle advice should be given to patients related to physical activity, rehabilitation, smoking, alcohol and dietary advice

- Monitoring. All patients with chronic heart failure require regular monitoring, which should include clinical assessment, functional status, fluid and nutritional status, cardiac rhythm, medication review, serum urea, electrolytes and creatinine

- Discharge. Patients with heart failure should generally be discharged from hospital when their condition is stable and medical management is optimal and the primary care team is aware of the management plan

- Supporting patients and carers. Management of heart failure should be seen as a shared responsibility between patient, carers and health-care professionals.

Author contact details

Mandy Hipkin, Artificial Heart Nurse Specialist, Royal Brompton and Harefield NHS Trust, Harefield Hospital, Harefield, Middlesex. UB9 6JH. Email: m.hipkin@rbh.nthames.nhs.uk

Acknowledgements
The authors would like to thank the following for their assistance: Dr N.R. Banner, Consultant Cardiologist, Transplant Unit; Mr A. Khaghani, Consulant Surgeon, Transplantation; Dr C. Bowles, Artificial Heart Specialist; Harefield Hospital. The authors also acknowledge the assistance of the Thoratec Corporation and Jarvik Heart Inc.

 

 

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