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Following the wave of COVID and the numerous protocols of INR -self-management for patients with LVAD, it has been demonstrated that patients can monitor and adjust their anticoagulation and achieve better time in therapeutic range (TTR) compared to standard monitoring and care by physicians. To achieve this goal, more INR tests are performed. Here we compare the TTR in self-management versus the standard treatment and the costs of these two strategies in a European context. Using a protocol established at St-Vincent Hospital in Australia, patients were offered to follow a training on anticoagulation and then manage their anti-vitamin K treatment independently (Auto-management). We then compared the TTR and the cost before and under this protocol. Costs are based on Swiss prices and converted into Dollars (1CHF=1.03US $). Test-strip cost $4.8 per unit, the lancet costs a few cents, and the INR machine (CoaguCheck) is available for $810. The combined cost of the blood test and its interpretation by a general physician (GP) is about $50. Since November 2021, 11 patients have been included in the protocol; these included no women, one patient with a HeartWare, and 10 with a HeartMate 3. The patients have been included in the protocol for a cumulative time of 80 months or a mean of 7.3 months per patient. One patient was transplanted, and none died. One patient had a haemorrhagic complication following colonoscopy under therapeutic INR (2.8), no patient suffered thrombosis, and no LVAD replacement was performed. We compare this group during the Standard Care (SC) and Auto-management (AM) period. During SC, the median TTR was 72% (IQR 63-78); during AM it increased to 90% (IQR 77-93). In SC, the INR control cost per day was $9.4 (IQR 6.6-13) on average, which decreased to $2.4 (IQR 1.9-2.6) per day in AM. INR monitoring occurred on average 5.9 (IQR 4.2-8.2) times per month in SC phase; while in AM patients measured their INR 13.1 (IQR 11.7-13.4) times per month. The cost of one day of INR within the therapeutic range was $13 under standard care, $5.0 in the first year on Auto-management. Despite being associated with more INR control, Self-management of anticoagulation by LVAD- patients are less expensive and results in a higher TTR. Self-management also promotes patient independence. It should be encouraged and expanded to other LVAD implant centres. [ABSTRACT FROM AUTHOR]

Infection occurring during ventricular assist devices support (VAD) is the third most common cause of mortality overall and the most common cause of morbidity after three months post implantation. Understanding the epidemiology, aetiology, and response to treatment with driveline (DL) infections is crucial to their optimal management. We retrospectively analysed VAD specific infections in patients with VADs implanted at our institution between January 2009 and January 2019. Data on associated clinic and treatment were collected. During this 10-year period, we implanted 94 patients, 22 (23%) females; 9 (10%) HeartMate 2, 18 (19%) HeartMate 3, and 63 (67%) HeartWare; 23 (25%) as destination treatment. Median age was 54. A total of 216 infectious episodes were documented. 38 patients (40%) had at least one episode of VAD-specific infection, with a median of 2 (IQR: 1-3) infections per patient. All were DL infections (no pump/pocket infection). Thirty-five different organisms were recovered from swabs, most frequently 102 (41%) S. aureus and 38 (15%) P. aeruginosa. The median time to first DL-infection was 162 days (IQR: 74-258). Data on DL infection treatment was documented for 198 infections, of which 134(67%) were treated with short-term antibiotics (< 4 weeks of treatment), 28 (14%) with suppressive antibiotic therapy(> 4 weeks of treatment) and 36 (18%) surgically. The median time from VAD-implantation to the first surgical DL-treatment was 169 days (IQR: 31-958) and 262 days (IQR: 15-673) to initiation of suppressive antibiotic therapy The median time to relapse was 86 days (IQR: 53-189) for short-term antibiotic therapy, 148 days for surgical intervention and 422 days (IQR: 209-807) for long term antibiotic therapy. A conclusion on treatment efficacy is not possible here. Nevertheless, the time to first infection or to relapse may be useful as a benchmark to assess new DL dressing techniques, treatment strategies or implantation techniques. [ABSTRACT FROM AUTHOR]

Electromagnetic interference (EMI) generated by the HeartMate3 (HM3) may disrupt initial "hand-shake" connectivity between an implanted defibrillator (ICD) and its external programmer. As the intensity of EMI is a function of VAD-ICD distance, manipulating this parameter may improve programmer connectivity. As the conventional position of ICDs is in the left pectoral muscle, arm movement influences the position of the ICD relative to the fixed intra-thoracic VAD position. Given the different arm positions utilised for CT (above the head) and chest x-ray (in front), we retrospectively analysed chest CT scans and chest X-rays (CXRs) of patients implanted with a VAD between March 2018 and March 2020. We analysed 32 X-rays and 22 CTs of 22 patients implanted with a VAD (5 HM3 and 17 Heartware). Seventeen patients had both a VAD and an ICD in situ, with majority (14/17) of these devices implanted on the left side. The mean distance between a left implanted ICD and the VAD was 11.7cm (IQR 10.8-13.2) on chest X-ray and 14.7cm (IQR 13.6-16.3) on CT. There was a significant discrepancy between CT and X-ray calculated distances with a median 3.3cm(IQR 2.2-4.0) greater distance when measured by CT (p=0.0003) in the same patient. There was no difference in distance between patients with HW and HM3 devices (p=0.6). In one patient with an HM3 and a Biotronic (Illivia) ICD-device that was unable to be interrogated, raising the arm above the head in supine position allowed reconnection, illustrating the practical application of this manoeuvre. There is a 3.3cm increase in the VAD-ICD distance when patients raise their arms above the head. This is an easily performed manoeuvre to overcome VAD EMI and needs to be more systematically studied. [ABSTRACT FROM AUTHOR]