*Perspective Chapter: Delivering LVAD Care to the Local Community DOI: http://dx.doi.org/10.5772/intechopen.111381*

occur in the local community, leading to improved access for patients with financial difficulties. This also improved patient compliance and diligence in attending all appointments, including seeking care as soon as issues arise. Other centers in the U.S. have demonstrated similar favorable outcomes with the shared-care model. A study published in JACC evaluated several key measures for LVAD patients implanted at the University of Utah Hospital. The authors included 336 patients implanted between 2007 and 2018, and categorized them based on level of care and resources utilized for their post implantation care. Overall, the rates of infection, bleeding, death, and pump thromboses were similar between care provided at the implanting institution (traditional care model) and outpatient care with LVAD specific training (the sharedcare model). Rates were higher when outpatient services that were utilized did not have LVAD specific training, highlighting the importance of ensuring proper LVADspecific training and resources are available at shared-care facilities [41].

There are no established criteria for shared care programs. However, a group of authors suggested several criteria that were published in the American Heart Association Journal Circulation, which focused on three broad categories: personnel, education, and equipment (**Table 1**). It is generally agreed that a shared care center should have an appointed local LVAD specialist—typically a heart failure cardiologist, though formal training in advanced heart failure is not a Joint Commission requirement for LVAD implantation facilities. Moreover, a nurse coordinator is another essential team member, who often serves as the primary contact for patients and other providers in the shared care team. Regarding education, LVAD specific training for all team members is essential. Preceptorships and LVAD vendors can provide the on-site education needed to learn the principles of LVAD management. Basic equipment should be garnered by the shared care facility and appropriate staff trained on its use. Device consoles, spare parts such as controllers, power cables, controller batteries, battery charges, and driveline equipment should ideally be available for timely replacement and troubleshooting [42].

Every follow-up visit starts with a review of systems concerning potential LVAD complications (**Table 2**). Next, is a blood pressure check which in continuous flow


#### **Table 1.** *Potential criteria for shared-care partners.*


#### **Table 2.**

*Symptoms in an LVAD patient.*

devices is typically taken as a mean arterial pressure obtained via doppler. This is done by inflating the sphygmomanometer to 20 mmHg above flow occlusion and the opening pressure is considered the systolic blood pressure if the patient has pulsatility. In absence of pulsatility, as in most LVAD patients, this is considered the MAP or mean arterial pressure. Recommended MAP is 60–80 mmHg [43] and MAPs outside of this range warrant intervention. One of the common alarms is "low flow" due to decrease in pump flow in both hyper and hypotension. Guideline directed medical therapy or neurohormonal antagonism must be continued to appropriately control blood pressure.

An ECG is recommended in every LVAD patient to evaluate for ventricular arrhythmias. Prompt attention to any signs and symptoms of right heart failure should warrant further investigation. Alarm interrogation and documentation is also necessary. Critical alarms include "VAD stopped" and "critical battery" of 5 minutes which display as a red triangle. A yellow flashing triangle necessitates evaluation by a LVAD specialist as it suggests the pump exceeds its power threshold. Non-flashing alerts require non-emergent evaluation and can be evaluated at the shared care center.

Additionally, laboratory tests are followed closely to ensure proper function of the LVAD. Regular INR checks, lactate dehydrogenase (LDH), and plasma free hemoglobin or hematocrit are measured regularly to monitor for adequate anticoagulation, as well as to monitor for hemolysis [44]. In addition, echocardiography is used to monitor ventricular function. Aortic valve insufficiency symbolizes inadequate function and leads to adjustment to LVAD parameters [45].

Driveline exit sites must be thoroughly inspected and suspicion of infection should be followed up with site culture, blood cultures, and appropriate imaging studies. This can be performed at the local shared care site as it does not require hardware manipulation. As infection rates are higher in this population and linked to a higher 1-year mortality, prompt treatment of infections with appropriate antibiotics is warranted [46]. GI bleeding is another complication that needs prompt evaluation and can be completed at any shared care site with GI services. As arteriovenous malformations (AVMs) are frequently the source of GI bleeding, urgent endoscopy can serve as diagnostic and therapeutic modality [47]. Reversal of INR is not ideal and requires careful monitoring as subtherapeutic states lead to pump thrombosis and failure. Neurologic complications, both hemorrhagic and cardioembolic strokes account for 19% mortality following an LVAD implant [12]. Due to its increasing prevalence, guidelines for LVAD patients were added to the cardiopulmonary resuscitation (CPR) algorithm in 2017. All staff at shared care centers must be able to recognize situations in which this protocol must be initiated. If the device hum is present, then controller function and adequate power must be confirmed. In the absence of the device hum, with MAP <50 mmHg, CPR should be initiated. However, with increasing time of pump discontinuation, the likelihood of pump thrombosis increases.

#### *Perspective Chapter: Delivering LVAD Care to the Local Community DOI: http://dx.doi.org/10.5772/intechopen.111381*

Extracorporeal membrane oxygenation (ECMO) can be considered in these scenarios if CPR is successful and further care should be transferred to a tertiary center [48].

Follow up care in an LVAD patient is key to a successful outcome (**Figure 2**). Houston Methodist, another implanting center who successfully employs the shared care model, developed an extensive protocol to be used at shared care sites and specified the steps taken for equipment checks from patient education to clinician verification [49]. Educating the new shared care site on management of LVAD visits and emergencies can be a challenge. There are no current guidelines on the training required by ancillary staff to conduct such visits. Allowing for this care to occur near a patient's home can prove to be a psychosocial advantage, encouraging family members involvement and support. If a regional center is trained in the basics of LVAD management, it would decrease inpatient transfers for non-LVAD related hospitalizations, thereby improving patient experience while increasing community hospital revenue [50].

The success of the shared care model can also allow former non-implantation sites to naturally evolve into implantation sites themselves. The lessons learned by its participation as a shared care site enabled DHLC to develop its own LVAD transplant program further expanding patient access to needed durable mechanical support. New implant centers will then develop their own selection committee for candidacy in accordance with the International Society of Heart and Lung Transplant Committee standards and guidelines. The patient is scored on the

**Figure 2.** *Follow up evaluation of LVAD patient.*

Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) scale with 1 noting critical cardiogenic shock and 3 as stable on continuous intravenous inotropic support. INTERMACS 4 through 7 are not typically considered for LVAD as they have not yet reached the severity level required and are managed with medications. Once the case is reviewed by the team, patients with an INTERMACS score greater than two can choose the location for further work up for implantation with a plethora of tests such as echocardiograms, CT scans, and colonoscopies which are used to maximize the patient's status for an optimal outcome. Once a LVAD is implanted, follow up care is transferred back to the referring heart failure specialist who can continue to manage the patient in conjunction with the LVAD team. While heart transplantation remains the goal for some patients, others have been rejected due to age or other comorbidities. With the increasing demand for LVADs as destination therapy, more shared care networks will likely make the transition to implantation centers as well.
