Biomedical subjects

J E Reedy

Publications and source records attributed to J E Reedy.

27 records · Page 2Linked to original sources

PubMedDate not supplied

Bridge to heart transplantation: importance of patient selection.

Since 1986, 26 candidates were evaluated for mechanical support as a bridge to heart transplantation. Group 1 consisted of 15 patients who were accepted and who received support with a ventricular assist device (14 patients) or a total artificial heart (1 patient). Seven of the 15 patients received transplants and survived, whereas contraindications to transplant developed in seven patients while they were receiving support, and these seven died. One patient remains hospitalized after transplantation. Group 2 consisted of 11 patients rejected for circulatory support because of renal insufficiency or infection (9), pulmonary embolus (1), and cerebrovascular accident (1). Two group 2 patients underwent transplant procedures after their complications resolved, and one survived. One other group 2 patient who recovered without transplantation or mechanical support was discharged. There was no significant difference in age, gender, or cause of cardiogenic shock between the two groups. Four of five patients accepted for mechanical support on the first evaluation survived, and three of 10 accepted after the initial evaluation survived, indicating that delayed selection often results in complications that preclude transplantation and survival. Only one of the 26 patients survived without transplantation or support. These data emphasize the importance of patient selection on the outcome of bridging to transplantation.

Adult↗

PubMedDate not supplied

Left ventricular versus left atrial cannulation for the Thoratec ventricular assist device.

In a retrospective study of 28 patients (23 men, 5 women) supported with ventricular assist devices greater than 3 days, the effect of LV cannulation versus LA cannulation on device performance was compared. Patients ranged in age from 12 to 67 years (mean 46 years) and were supported for 3-81 days (mean 15 years). Fifteen patients were supported with left VADs (6 LV and 9 LA), and 13 patients were supported with BVADs (5 LV and 8 LA). The mode of operation 91% of the time was the fill-to-empty mode. Ten data points were taken for each patient. LV cannulation results in higher VAD flow index at decreased preload, lower VAD systolic and vacuum pressures, and shorter diastolic durations. Eleven of the 28 patients survived. Although survival was greater in patients with LV cannulation, survival was more dependent upon reversibility of myocardial damage, eligibility for transplantation, or the development of complications. These data indicate that LV cannulation provides better VAD performance than LA cannulation in the fill-to-empty mode.

Adolescent↗

PubMedDate not supplied

Oral anticoagulation in patients with ventricular assist devices.

Nine men aged 25-63 years (mean 42 years) received pulsatile ventricular assist devices (VADs) as a bridge to cardiac transplantation. Duration of support ranged from 8-266 days (mean 70.7 days); seven patients (pts.) were bridged with a LVAD and two received BVADs. All pts. were maintained on oral anticoagulants after initial intravenous (IV) heparin or dextran therapy. During warfarin therapy, supplemental IV heparin was used only if the prothrombin time fell below 1.5 times control (approximately 30% activity). In 639 days of support, there was one thromboembolic event due to mechanical failure, and one pt. had thrombus in the VAD which did not embolize.

Administration, Oral↗

PubMedDate not supplied

Nursing care of the ambulatory patient with a mechanical assist device.

Since 1986, 10 men and one woman were ambulatory while supported with mechanical assist devices as a bridge to heart transplantation. Four patients received a subclavian intraaortic balloon pump, two were supported with a Novacor left ventricular assist system, three patients received Pierce-Donachy ventricular assist devices, and one patient received a Jarvik 7 total artificial heart. One patient with an intraaortic balloon pump later received a left ventricular assist system because of hemodynamic deterioration despite the intraaortic balloon pump. Before device insertion all 11 patients were in cardiogenic shock despite inotropic and vasodilator support. The time of support ranged from 8 to 440 days (median, 24 days). In-house coverage by the circulatory support team was necessary only during the first 24 to 72 hours of support. When the patient's condition was stabilized, nursing staff monitored the devices with "on-call" availability of the circulatory support team. After implant of the device, all patients were able to perform activities of daily living. Once patients were able to walk in their hospital rooms, ambulation began in the hallways; frequency and distance were gradually increased. Four of the patients walked outside the hospital while tethered to the drive console. Daily physical therapy contributed to increased exercise tolerance. Protective isolation was used before and after transplantation to minimize the risk of infection. Sterile dressing changes (gown, gloves, mask) were applied to drive lines, cannula sites, and incisions. All invasive lines and catheters were removed as soon as the patient's clinical condition warranted, and noninvasive monitoring was used to decrease the chance of infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMedDate not supplied

Retrospective analysis of the psychologic effects of mechanical circulatory support.

There is an increasing need to evaluate the psychologic impact of circulatory support because of the growing use of mechanical assist devices. Twenty-seven people, 12 survivors of mechanical circulatory assistance and 15 family members, were surveyed; nonsurvivors' families were not surveyed. The 12 survivors (ages 18 to 66 years; mean, 43 years) had been supported with Pierce-Donachy ventricular assist devices (nine patients) and the Novacor left ventricular assist system (one patient). One patient received a centrifugal pump, and one was supported with extracorporeal membrane oxygenation (ECMO). Duration of support ranged from 8 hours to 90 days (mean, 23 days). Ten people surveyed were spouses of these patients, and five were parents of children who had been supported with ECMO. Three patients were supported longer than 3 weeks, and four patients were awake and ambulatory during support. Financial worries were not a concern for 80% of the parents but were a concern for 80% of the spouses. Eighteen percent of the patients believed they were treated as an experiment, whereas 40% of their spouses thought they were. None of the parents thought their child was treated as an experiment. Sixty-seven percent of the patients stated that they have returned to a normal life-style, and 75% feel they have a brighter outlook on life. Six patients have returned to work, two are retired, two are disabled, and two have physical capabilities to work but choose not to. Eighty-nine percent of all those surveyed would recommend an assist device to someone who needed one. Although these procedures are often associated with severe medical and psychologic complications, 74% of the patients would agree to a second implant.

Adult↗

PubMedDate not supplied

Nursing care of a patient requiring prolonged mechanical circulatory support.

Four cardiac transplant candidates were supported with ventricular assist devices for periods ranging from 53 to 90 days (mean, 75 days). The patients were men who ranged in age from 36 to 49 years (mean, 44.5 years). Two patients had Pierce-Donachy biventricular assist devices (BVADs) and two patients had Novacor left ventricular assist systems (LVASs). Complications included infection (3 patients), development of antibodies (2 patients), bleeding (2 patients), and pump inflow obstruction (1 patient). All patients were maintained on an anticoagulation regimen which included warfarin and dipyridamole. They were extubated and ambulatory for most of the period of mechanical support. Thromboembolic complications did not develop in any of these patients, and they did not acquire infections which involved the mediastinum. They were successfully transplanted and discharged 11 to 25 days after transplantation. Although major complications were common in this small group of patients, all four patients achieved hemodynamic stability and became excellent candidates for cardiac transplantation. With proper patient selection and meticulous nursing care, current mechanical circulatory support technology is capable of maintaining patients consistently for periods of greater than 50 days.

Adult↗

PubMedDate not supplied

Evaluation of an implantable ventricular assist system for humans with chronic refractory heart failure. Measuring quality of life.

The development of a multidimensional quality of life protocol to be used in a clinical trial of an LVAS was presented. The complexity of the new LVAS technology being evaluated added a unique dimension for HQL assessment. The rationale and procedures used in developing this protocol were described. Although we have elucidated the development of a protocol for a specific clinical trial, the principles and procedures employed are widely applicable. To summarize, these procedures are as follows: 1. Determine what quality of life domains are important to measure. This decision should be based upon the domains expected to be affected by treatment, those expected to change as a result of the natural course of the disease or condition, and those that may be affected by changes in the primary domains. 2. Once the domains are selected, identify specific measures for these domains. Where possible, the measures chosen should be standardized, well validated, and appropriate to the study population. Instrument length and mode of administration are additional considerations. 3. Consider any unique aspects of the study population or intervention and develop specific questions to address them. 4. Identify and measure important variables that may moderate or influence quality of life. 5. Test the protocol on an appropriate population for length, flow, and ease of administration. Copies of the complete HQL protocol are available by writing to: Dr. Nancy Avis, New England Research Institute, 9 Galen Street, Watertown, MA 02172.

Clinical Protocols↗

PubMedDate not supplied

Heart transplantation charges: status 1 versus status 2 patients.

BACKGROUND: The current health care environment mandates closer scrutiny of health care dollar allocation. To better understand the distribution of heart transplantation costs, we reviewed hospital and physician billing of patients who underwent orthotopic heart transplantation between August 1988 and September 1993. METHODS: This study is a retrospective review of 107 consecutive cases. Charges and clinical results of United Network for Organ Sharing status 1 patients (n = 46), including 17 bridge to transplantation patients, were compared with those of United Network for Organ Sharing status 2 patients (n = 57). Charges were converted to 1992 dollars. RESULTS: During the first 12 months of the study, 77% of heart transplantations were performed in United Network for Organ Sharing status 2 patients, whereas over the last 12-month period, 25% of the transplantations were performed in status 2 patients. No significant differences were found in age, gender, type of cardiomyopathy, or survival between the status 1 and status 2 groups. The length of hospitalization for the status 1 group ranged from 8 to 138 days (mean 49 days) as opposed to 5 to 82 days (mean 17.5 days) for the status 2 group (p < 0.0001). Pretransplantation hospital charges were significantly higher for the status 1 group ($47,917 to $341,215, mean $109,116) when compared with status 2 ($0 to $10,035, mean $250) (p < 0.0001). No significant difference was found in posttransplantation hospital charges between status 1 ($47,917 to $210,027, mean $95,379) and status 2 patients ($48,093 to $380,745, mean $102,265). Total charges were significantly higher (p < 0.0001) for the status 1 group ($89,910 to $512,331, mean $239,375) when compared with the status 2 group ($63,885 to $455,680, mean $128,594). Total transplantation charges for the study period were $18,341,108. This amount could have paid for 77 status 1 transplantations or 143 status 2 transplantations. CONCLUSIONS: If current trends continue and the donor pool remains the same, most transplant recipients will be status 1, resulting in a comparable number of transplantations performed at twice the charges.

Cardiomyopathies↗

PubMedDate not supplied

Transfer of a patient with a ventricular assist device to a non-critical care area.

Ventricular assist device (VAD) support has traditionally been associated with critically ill patients. Indeed, a VAD is inserted as the last hope for patients with cardiogenic shock who are unresponsive to conventional therapy. However, many patients bridged to potential cardiac transplantation are no longer critically ill after hemodynamic stabilization is achieved with VAD support. The focus of this article is to provide guidelines established for the transfer and provision of quality nursing care for patients with a VAD on a general cardiothoracic nursing floor.

Adult↗