**3. Traditional LVAD care model**

In traditional advanced heart failure centers, the care for these patients was provided by large multidisciplinary teams involving multiple coordinators, nurses, physician assistants, cardiothoracic surgeons, palliative care, and various advanced heart failure specialists. Due to the costs associated with such a large team, LVAD care was historically limited to large, urban medical facilities [15, 16]. Post-transplantation inpatient cardiac rehabilitation allows patients to improve their functional status. This also allowed for adjustment of LVAD settings as vital signs fluctuated with the body's adjustment to altered hemodynamics. Since patients with LVADs do not have a true systolic blood pressure, their mean arterial pressure (MAP) can be measured with a portable doppler by a trained professional. In addition to the vital signs, the degree of

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

anticoagulation requires close monitoring as early data suggests that direct oral acting agents carry an increased risk of thrombotic events [17–19].

Patients and caregivers are required to attend extensive educational sessions at all LVAD implantation centers. These sessions evaluate patients' functional status in an effort to avoid catastrophic errors while performing daily care such as changing batteries, bathing, or responding to device alarms [20]. Training the patients to manage the driveline using sterile technique is extensive. Standardized kits have been generated to aid in the process, but driveline site infections remain a major concern and a cumbersome task for the patient [11, 21]. Driveline care requires significant adjustment to lifestyle, including intimate relationships. Patients are directed to be exceedingly careful to avoid pressure on equipment or excessive body movements near the exit site [22]. Similar to other major cardiac surgeries, after appropriate rehabilitation and wound healing, driving is permitted. Traveling requires additional preparation to ensure back ups to all equipment is available along with a LVAD site at destination [23].

While a multidisciplinary team optimizes care of an LVAD patient, a recent national survey of cardiologists, LVAD advanced practice providers, coordinators, surgeons, and social workers failed to identify the characteristics that would make an ideal patient [24]. Patients with higher education levels (>12 years) had higher survival rates [25]. The Singapore LVAD program has stricter selection criteria, however, the program's outcomes were similar to the IMACS registry. They did report a higher 3 year survival, but also a higher infection rate [26].

LVAD patients are frequently hospitalized due to complications with as many as 80% of all patients having had at least one admission by the 1 year mark [11]. Most commonly, they present with gastrointestinal bleeding (GIB) or a driveline infection. Optimal social support and meticulous adherence to LVAD management have been noted in conjunction with reduction in unplanned admissions. In 2020, there was a case report noting 4 years as the longest time interval to hospitalization for an LVAD patient. University of Chicago has conducted many trials investigating the infrastructure leading to LVAD success. They suggest the continuation of GDMT to decrease HF recurrence, omega-3 to decrease GIB [27, 28], bi-monthly international normalized ratio (INR) checks to maintain therapeutic anticoagulation [29], and a coordinator team to address all device alarms as measures to prevent adverse events and related unplanned readmissions [30]. The Miami Transplant Institute conducted a CF-LVAD study which showed anticoagulation management by a pharmacist along with self-testing improved the duration of time spent in therapeutic range [31]. With advancing technology, telehealth may serve as an adjunct to improving patient care. A small study utilizing a LVAD specific platform where patients entered their parameters followed by health surveys improved patient satisfaction. This platform gives patients the ability to review LVAD educational materials and track their individual data which has the potential to reduce readmissions [32–34].

Traditionally, the LVAD patient would remain associated with that implanting facility, regardless of the patient's distance traveled to the facility, socioeconomic limitations, time constraints and other factors. While this model encourages continuity of care in large cities with multiple healthcare centers, it discourages use of advanced therapies in patients who live outside of large cities [35, 36].
