Challenging the grim perception of congestive heart failure (CHF) diagnoses, WellSpan Heart & Vascular couples surgical expertise with leading-edge technology to help CHF patients live longer, more active lives, with fewer limitations.
A condition resulting from the heart’s failure to meet the body’s metabolic needs, CHF can cause shortness of breath, fatigue, edema, tachycardia and weakness. At first, patients may experience difficulties only during physical activity. In later stages, however, symptoms are evident even during periods of rest; patients may be unable to perform basic functions, such as standing and walking, without distress. CHF patients account for 34 percent of heart-related deaths in the United States — about 277,000 annually. CHF is the most common reason elderly patients are hospitalized, and it generates high rates of rehospitalization. Patients in advanced heart failure typically have approximately a 50 percent chance of surviving one year.
However, numerous advances are lengthening the lives of CHF patients while restoring their ability to participate in a range of fulfilling activities. WellSpan Heart & Vascular, recently certified as a Ventricular Assist Device (VAD) Destination Therapy Center by The Joint Commission, provides patients comprehensive, advanced treatments in the form of medical and social support, as well as life-extending VADs.
“Left ventricular assist devices (LVADs) have a long history,” says David J. Kaczorowski, MD, VAD surgeon, attending cardiac surgeon and Director of Mechanical Circulatory Support at WellSpan York Hospital. “There is clear data from rigorous studies that these devices improve not only patient survival but also quality of life.”
LVADs have become popular in recent years for long-term circulatory assistance. They have evolved from large, pulsatile devices to smaller, continuous-flow devices that fit a greater variety of patients, including men of small stature and women. Patient outcomes have improved from even just a few short years ago. In a 2009 study, 68 percent of CHF patients who received a continuous-flow LVAD were still alive one year after surgery, and 58 percent survived two years; more recent registry data show up to 80 percent survival one year after LVAD implantation.
WellSpan Heart & Vascular specialists utilize multiple advanced LVADs for CHF patients, with one of the most common being Thoratec’s HeartMate II. This lightweight device is powered via an external controller the patient wears securely around the waist, enabling him or her to undertake a more active lifestyle. The HeartMate II features adjustable speeds and an alarm to warn the patient of malfunctions.
“As a Ventricular Assist Device Destination Therapy Center certified by The Joint Commission, we implement best practices to meet quality guidelines. Our specialized staff and highly qualified surgeons coordinate care to ensure patients experience the best results possible with their LVADs.”
— Julie Miksit, MBA, BSN, RN, Vice President of WellSpan Heart & Vascular
Approximately 14,000 patients have received the HeartMate II, Dr. Kaczorowski says, and of those, 6,000 use it for ongoing support. More than 100 have survived five or more years. Additionally, patients experience significant relief from CHF’s symptoms, and many gain renewed ability to participate in everyday activities such as walking.
Preparation, Procedure and Follow-up
Dr. Kaczorowski and Danielle Bielecki discuss the technology used in a VAD procedure.
Before surgery, the collaborative team works with patients and their caregivers to help them understand the procedure and to get patients in the best shape possible.
“We let them handle the device,” says Danielle Bielecki, CRNP, VAD Coordinator at WellSpan Health. “We also explain what will happen during their surgery.”
Expert physicians such as Dr. Kaczorowski, a fellowship-trained cardiothoracic surgeon, perform the implantation surgeries.
“After performing a sternotomy, we create a small pocket for the device,” he explains. “We then place the patient on a bypass machine. We remove a core of tissue from the apex of the left ventricle. The device cannula is sewn to the apex of the heart. The driveline is brought out through the chest wall and attached to the external battery, while the outflow graft is sewn to the ascending aorta. We then activate the device and gradually wean the patient off the bypass, after which we close the sternum and incisions.”
Dr. Kaczorowski also notes that a multidisciplinary team, including cardiologists, VAD coordinators and cardiac surgeons, continues to monitor the patient after surgery, making medical and pump function adjustments.
“These patients have ongoing medical needs, including chronic anticoagulation, equipment needs and detailed medical management,” he says. “Our team approach ensures these lifelong issues are addressed in a coordinated fashion.”
That approach involves close follow-up coordination with caregivers as well.
“After surgery, once a patient is recovering well, we bring his or her caregiver in again for ongoing education,” Bielecki says. “We work with the patient and caregiver extensively until the patient goes home or to an inpatient rehabilitation program.”
WellSpan Heart & Vascular patients who receive LVADs have four paths available to them, Dr. Kaczorowski says. Some use LVADs as a “bridge to heart transplant.” Others, whom Dr. Kaczorowski refers to as “bridge-to-decision” patients, receive an LVAD and later make a determination whether they will have a heart transplant. Still others, “bridge-to-recovery” patients, may use temporary LVADs after a cardiac event while the heart recovers. Many, though, are “destination therapy” patients, who will have their LVADs for the remainder of their lives.
“We started implanting LVADs here in 2006,” Bielecki says. “We have expanded over the years; initially, we mainly used LVADs for CHF patients who needed a bridge to transplant. Now, the criteria for LVAD implementation have expanded so that non-bridge candidates are eligible as well.”
“Any physician who has a patient with congestive heart failure should consider referring them to WellSpan Heart & Vascular. If they have an ejection fraction that is slowly diminishing, combined with worsening symptoms, we may be able to maximize their status. Even if they are not yet candidates for LVAD implantation, we will be able to follow them and act quickly if things change.”
— Danielle Bielecki, CRNP, VAD Coordinator at WellSpan Health
Since 2006, Bielecki continues, WellSpan has performed more than 20 LVAD implantation procedures. Additionally, the VAD program follows patients who are not yet candidates for surgery, with their suitability for a given procedure potentially changing over time, depending upon a range of health, lifestyle and other factors.
“If CHF patients come to us electively and their ejection fraction is less than 10 percent, we can use their age as a determinant,” Bielecki says. “Patients who are younger than 70, whose BMI is less than 30 and who have not smoked for at least six months are candidates for LVAD implantation as a bridge to transplant. Those who do not meet transplant criteria may be able to receive an LVAD and be reconsidered for transplant if they lose weight and become tobacco-free.”
A skilled team of nurses, social workers, and physical and occupational therapists receives ongoing training to address not only LVAD patients’ physical needs but also the socioeconomic issues they might face.
“There are many social and financial challenges our patients may need to overcome,” Bielecki says. “For instance, they must be able to maintain electric and telephone service to their home at all times. Some do not have the ability to do this. We ensure they have a backup plan if their power goes out and they need to recharge their batteries. We are very diligent in taking care of these details.”
Referring physicians are valuable partners in the ongoing care of LVAD destination therapy patients, and Dr. Kaczorowski recommends early referral to produce the best patient outcomes possible. Once those connections are established, the cardiologists and cardiac surgeons at WellSpan Heart & Vascular work in tandem with family physicians to co-manage LVAD patients.
Care coordination doesn’t stop with primary care providers, however. WellSpan reaches out to emergency medical services (EMS) providers covering the territory where LVAD patients live, as well. EMS providers learn which patients in their coverage area have LVADs and how to care for unresponsive patients.
“Some of our patients may not have a pulse,” Bielecki says. “This could lead EMS providers to think they are having a cardiac event when they are not. We send out nationally approved guides to medics so they understand how to treat our patients appropriately.”
From left: David Kaczorowski, MD, cardiothoracic surgeon; Danielle Bielecki, CRNP, VAD Coordinator; Peter Barclay, MD, cardiologist; and Dana Gaultney, RN, Open Heart Intensive Care Unit
Patients’ goals govern the course of therapy, from diagnosis to path choice to the return to home and community. Many LVAD patients at WellSpan Heart & Vascular have rediscovered activities they enjoy, such as shopping, golfing, traveling or spending time with family.
“This is something important for us to do for our patients,” says Julie Miksit, MBA, BSN, RN, Vice President of WellSpan Heart & Vascular. “We are able to provide advanced treatment for CHF patients while keeping them close to home.”
To learn more about WellSpan Heart & Vascular, visit wellspan.org/heartandvascular or call 717-851-6454.