HFA of the ESC position paper on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider Part 3: at the hospital and discharge

The growing population of left ventricular assist device (LVAD)-supported patients increases the probability of an LVAD- supported patient hospitalized in the internal or surgical wards with certain expected device related, and patient-device interaction complication as well as with any other comorbidities requiring hospitalization. In this third part of the trilogy on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider, definitions and structured approach to the hospitalized LVAD-supported patient are presented including blood pressure assessment, medical therapy of the LVAD supported patient, and challenges related to anaesthesia and non-cardiac surgical interventions. Finally, important aspects to consider when discharging an LVAD patient home and palliative and end-of-life approaches are described

Self-care behaviours of patients with left ventricular assist devices in Israel: changes during the COVID-19 pandemic

AimsLeft ventricular assist devices (LVADs) support the hearts of patients with advanced heart failure. Following LVAD implantation, patients face a complex regimen of self-care behaviours including self-care maintenance, self-care monitoring and self-care management. However, during the COVID-19 pandemic, symptoms of anxiety and depression may have interfered with their self-care. Currently, little is known on how specific self-care behaviours of LVAD-implanted patients changed during the COVID-19 pandemic. We aim to describe the changes in self-care behaviours among patients with an implanted LVAD in Israel during the COVID-19 pandemic and explore the factors related to self-care behaviour change. MethodsA prospective observational cross-sectional study design. A convenience sample of 27 Israeli LVAD-implanted patients (mean age 62.4 +/- 9, 86% male, 78.6% living with a partner) completed the LVAD Self-Care Behaviour Scale (1 = never to 5 = always) and Hospital Anxiety and Depression Scale (0 = not at all to 3 = most of the time). Data were collected before and after the onset of the COVID-19 pandemic in Israel. Statistical analyses included paired t-tests, Pearsons correlations, and one-way repeated measures ANOVAs. ResultsDuring the COVID-19 pandemic, a significant decrease was found in patients adherence to checking and recording their LVAD speed, flow, power and PI (Pulsatility Index) (P = 0.05), checking their INR (P = 0.01), and daily weighing (P &amp;lt; 0.01). The prevalence of some behaviours (e.g. regularly exercising) increased in some patients and decreased in others. Patients living without a partner worsened their adherence to some of the self-care behaviours (e.g. taking medicines as prescribed), compared with those living with a partner (M-b = 5.0 +/- 0 and M-d = 5.0 +/- 0, delta = 0 vs. M-b = 5.0 +/- 0 and M-d = 4.6 +/- 0.9, delta = -0.4, respectively; F = 4.9, P = 0.04). Women, and not men, tended to improve their adherence to the self-care behaviour such as avoiding kinking, pulling, or moving the LVAD driveline at the exit site (M-b = 4.0 +/- 1.0 and M-d = 5.0 +/- 0, delta = 1.0 vs. M-b = 4.5 +/- 0.9 and M-d = 4.4 +/- 1.2, delta = -0.1, F = 4.7, P = 0.04, respectively). In total, 41% (11) patients reported neither anxiety nor depression, 11% (3) reported anxiety, 15% (4) reported depression, and 44% (12) reported both anxiety and depression. No associations between anxiety and/or depression and self-care behaviours were found. ConclusionsPriorities in self-care behaviours among patients with implanted LVAD changed after the onset of the COVID-19 pandemic. Factors that assisted with adherence to self-care behaviours included living with a partner and being female. The current results may guide further research on identifying behaviours that are at risk of not being maintained during a time of emergency.Funding Agencies|Nursing &amp; Allied Professional Training Grant from the ESC (European Society ofCardiology)</p

Combined mechanical circulatory support for ventricular fibrillation in left ventricular assist device patient

Abstract Ventricular fibrillation, a life‐threatening ventricular arrhythmia, may result in pulselessness, loss of consciousness and sudden cardiac death. In this case report, we describe our experience in managing a 54‐year‐old man with HeartMate3 left ventricular assist device (LVAD) as a bridge to transplantation due to dilated non‐ischemic cardiomyopathy, presenting with incessant ventricular arrhythmia for 35 days despite multiple attempts to restore normal rhythm with external direct current cardioversion and anti‐arrhythmic medications. The patient remained stable in ventricular arrhythmia with no progression to asystole, but hemodynamic collapse due to right heart failure occurred in the third week. Combined use of two mechanical circulatory support devices (LVAD with VA ECMO) was needed to achieve haemodynamic and metabolic stability, eventually leading to successful heart transplantation in the index admission. The patient was discharged home 2 weeks after transplantation in good clinical condition

Exergaming in patients with a left ventricular assist device : a feasibility study

Aims Exercise games (exergames) have been recently proposed as a mode of facilitating physical activity in patients with chronic diseases. Although patients supported with left ventricular assist devices (LVADs) benefit from physical activity, specific LVAD-related issues hinder their ability to exercise properly. The objective of this study was to assess the feasibility and safety of exergaming in LVAD-supported patients. Methods and results Eleven LVAD-supported patients were enrolled in a 4 week exergaming programme using Nintendo Wii console with five sport games. Patients were instructed to play for 30 min a day, 5 days a week. Data on exercise capacity and exergaming were collected by using the 6 min walk test (6MWT) and a daily self-report diary, respectively. Feasibility of using the console and its safety was assessed by a semi-structured patient interview. Quality of life was assessed by the Minnesota Living with Heart failure Questionnaire (MLHFQ) and the Cantrils Ladder of Life. Safety was assessed by patients report in interview and diary. The study group consisted of 10 male patients and 1 female patient, mean age of 67 +/- 7 years, of whom 10 were supported with the HeartMate 3 LVAD for a median of 10 (interquartile range 3, 21) months. Baseline exercise capacity assessed by the 6MWT ranged from 240 to 570 m (mean 448 +/- 112). After 4 weeks of exergaming, 6MWT distance increased from a mean of 448 +/- 112 (evaluated in six patients) to 472 +/- 113 m (P = 0.023). Patients Cantrils Ladder of Life score improved numerically from an average of 6.13 to 7.67, as did their MLHFQ score from 45.9 +/- 27 to 38.7 +/- 18, with higher and lower scores, respectively, reflecting higher quality of life. No specific LVAD-related safety issues regarding exergaming were reported. Conclusions Exergaming was found to be a safe and feasible mode for encouraging physical activity in LVAD-supported patients and carries a potential for improving exercise capacity and quality of life in these patients. Larger scale studies are warranted to further investigate the effect of exergaming in this patient population.Funding Agencies|Swedish National Science Council [2016-01390]</p

The plasmid-encoded Ipf and Klf fimbriae display different expression and varying roles in the virulence of <i>Salmonella enterica</i> serovar Infantis in mouse vs. avian hosts

<div><p><i>Salmonella enterica</i> serovar Infantis is one of the prevalent <i>Salmonella</i> serovars worldwide. Different emergent clones of <i>S</i>. Infantis were shown to acquire the pESI virulence-resistance megaplasmid affecting its ecology and pathogenicity. Here, we studied two previously uncharacterized pESI-encoded chaperone-usher fimbriae, named Ipf and Klf. While Ipf homologs are rare and were found only in <i>S</i>. <i>enterica</i> subspecies diarizonae and subspecies VII, Klf is related to the known K88-Fae fimbria and <i>klf</i> clusters were identified in seven <i>S</i>. <i>enterica</i> subspecies I serovars, harboring interchanging alleles of the fimbria major subunit, KlfG. Regulation studies showed that the <i>klf</i> genes expression is negatively and positively controlled by the pESI-encoded regulators KlfL and KlfB, respectively, and are activated by the ancestral leucine-responsive regulator (Lrp). <i>ipf</i> genes are negatively regulated by Fur and activated by OmpR. Furthermore, induced expression of both <i>klf</i> and <i>ipf</i> clusters occurs under microaerobic conditions and at 41°C compared to 37°C, <i>in-vitro</i>. Consistent with these results, we demonstrate higher expression of <i>ipf</i> and <i>klf</i> in chicks compared to mice, characterized by physiological temperature of 41.2°C and 37°C, respectively. Interestingly, while Klf was dispensable for <i>S</i>. Infantis colonization in the mouse, Ipf was required for maximal colonization in the murine ileum. In contrast to these phenotypes in mice, both Klf and Ipf contributed to a restrained infection in chicks, where the absence of these fimbriae has led to moderately higher bacterial burden in the avian host. Taken together, these data suggest that physiological differences between host species, such as the body temperature, can confer differences in fimbriome expression, affecting <i>Salmonella</i> colonization and other host-pathogen interplays.</p></div

Klf and Ipf are induced at the avian physiological temperature.

<p>(<b>A</b>) qRT-PCR showing the fold change in the transcription of <i>ipfA</i>, <i>ipfB</i>, <i>ipfC</i> and <i>ipfD</i> in cultures grown in LB to the stationary phase under microaerobic conditions at 27°C or 41°C, relative to 37°C. (<b>B</b>) qRT-PCR showing the fold change in the transcription of <i>klfC</i>, <i>klfD</i>, <i>klfE</i> and <i>klfG</i> in cultures grown in LB to the stationary phase under microaerobic conditions at 27°C or 41°C, relative to 37°C. One way ANOVA with Dunnett's Multiple Comparison Test were performed to determine statistical significance. ns, not significant; *, P<0.05; **, P<0.01; ***, P<0.001. <b>(C)</b> Whole cell lysates of <i>S</i>. Infantis strains expressing a 2HA-tagged version of IpfD and KlfC that were grown in LB to the stationary phase under microaerobic conditions at 37°C and 41°C were separated on an SDS-PAGE. Western blotting using anti-HA antibody and anti-RpoD (as a loading control) are shown. The double band shown for KlfC-2HA and IpfD-2HA represents the premature and the signal peptide-cleaved forms of the proteins. IpfD-2HA and KlfC-2HA bands densitometry (normalized to the corresponding RpoD bands) are presented relative to the wt, under the RpoD blot.</p

The expression profile of <i>ipf</i> and <i>klf</i> in the mouse model.

<p>Female C57BL/6 mice (five animals per group) were infected orally with ∼8×10⁸ CFU of <i>S</i>. Infantis strains harboring luciferase reporter fusion with <i>ipf (ipf</i>::<i>lux)</i> <b>(A, C)</b> and <i>klf</i> (<i>klf</i>::<i>lux</i>) (<b>B, D</b>). Twenty four hours p.i. mice were sacrificed and their intact GI tract was removed and imaged immediately using a photon-counting <i>in-vivo</i> imaging system. (<b>A</b> and <b>B</b>) Bacterial loads in the cecum, colon and ileum are indicated by total CFU counted in the entire organ. Each dot indicates the count in an entire organ in a single animal. (<b>C</b> and <b>D</b>) The detected bioluminescence signal is shown as pseudocolor images, with variations in color representing light intensity at a given location. The color bar indicates relative signal intensity (as photons s⁻¹ cm⁻² sr⁻¹) and the minimal and maximal values measured are indicated in the box below each image. Different organs are indicated as follow: jejunum (J); ileum (I); cecum (CE); and colon (C).</p

Ipf and Klf contribute differently to <i>S</i>. Infantis infection in mouse vs. chicken.

<p>(<b>A-C</b>) C57BL/6 mice were intragastrically infected with ~6×10⁶ CFU of a mixed (1:1) inoculum containing the wild-type <i>S</i>. Infantis (harboring pWSK129; Km^R) and <i>klf</i> (<b>B</b>) or <i>ipf</i> (<b>C</b>) null mutant strain (harboring pWSK29; Amp^R). A mixed inoculum of two <i>S</i>. Infantis wild-type strains carrying pWSK29 or pWSK129 was used as a control (<b>A</b>). Four days p.i., mice were sacrificed and tissues were harvested aseptically, homogenized and plated on selective XLD agar plates for bacterial enumeration. Each dot represents a competitive index (CI) value in one mouse in a single organ (cecum, colon or ileum). The CI was calculated as [mutant/wild-type]_output/[mutant/wild-type]_input. (<b>D</b> and <b>E</b>) Two groups of one day old SPF White Leghorns chicks were infected orally with ~1×10⁷ CFU of 1:1 mixed inoculum containing the wild-type <i>S</i>. Infantis (harboring pWSK129) and <i>ipf</i> or <i>klf</i> deletion mutant strains (harboring pWSK29). Three days p.i. chicks were sacrificed and the indicated organs were homogenized and plated on XLD agar plates supplemented with ampicillin or kanamycin for bacterial numeration. The CI was calculated as above.</p

Genetic organization and phylogenetic distribution of the <i>ipf</i> and <i>klf</i> clusters.

<p>The pESI-encoded <i>ipf</i> and <i>klf</i> gene clusters were compared using the Easyfig tool with homologous clusters found in the nr database. Nucleotide comparison between the related clusters is illustrated by the shades of grey that indicate the degree of sequence homology (in %). Gaps in the grey areas point to the lack of sequence similarity, and protein functions (regulator, usher, chaperone and fimbrial subunit) are color-coded. <b>(A)</b> The <i>ipf</i> cluster encodes four ORFs: IpfA, a fimbrial protein; IpfB, the fimbrial chaperone; IpfC, the fimbrial usher; and IpfD, a putative fimbrial adhesin. Homologs of the <i>ipf</i> cluster were found in <i>Salmonella enterica</i> subsp. diarizonae strain 11–01854 (GenBank: CP011292.1) and in <i>Salmonella enterica</i> subsp. VII integrative and conjugative element ICESe3 region, strain SARC16 (sequence ID: FN298495.1). <b>(B)</b> The <i>klf</i> cluster in <i>S</i>. Infantis 119944 contains 12 ORFs encoding the major fimbrial subunit (KlfG), usher (KlfD), chaperone (KlfE) and four minor subunits (KlfC, KlfF, KlfH and KlfI). KlfJ, KlfK and KlfA have unknown function and KlfL and KlfB are unique to pESI and function as regulators (see <a href="http://www.plospathogens.org/article/info:doi/10.1371/journal.ppat.1006559#ppat.1006559.g008" target="_blank">Fig 8</a>). Similarity to the <i>fae</i> cluster in enterotoxigenic <i>E</i>. <i>coli</i> (GenBank: CP002730) is shown at the upper line of the alignment. Homologous clusters among <i>S</i>. <i>enterica</i> serovars were found in <i>S</i>. Anatum str. USDA-ARS-USMARC-1735 (GenBank: CP007584.2); <i>S</i>. Bareilly str. CFSAN000189 (GenBank: CP006053); <i>S</i>. Bredeney str. CFSAN001080 (GenBank: CP007533); <i>S</i>. Schwarzengrund str. CVM19633 (GenBank: CP001127.1); <i>S</i>. Montevideo str. USDA-ARS-USMARC-1921 (GenBank: CP007540.1); <i>S</i>. Typhimurium strain FORC_015 (GenBank: CP011365); and <i>S</i>. Cubana str. CFSAN002050 (GenBank: CP006055.1). The G+C content is illustrated by the blue-red histogram, at the top of the panel, while G+C > 50% is shown in red and G+C < 50% is shown in blue.</p