Teleconsultation for Left Ventricular Assist Device Patients: A New Standard of Care

Continuous-flow ventricular assist device (VAD) is a reliable treatment for patients with end-stage heart failure and represents an alternative to heart transplantation in selected cases. Following VAD implantation and hospital discharge, patients can be managed at home by means of a complex and integrated assistance programme that requires intensive cooperation between the referral centre, peripheral sites, caregivers, and patients themselves. To optimize VAD patients' outcome, a close follow-up has been demonstrated to be of utmost importance to avoid major complications,1, 2 but the intensity and modality of such a surveillance have not yet been well determined. Several studies have shown the importance of daily monitoring for data recording in the management of patients with advanced heart failure.3, 4 Furthermore, routine assessment of left VAD controller log files would be useful for the evaluation of pump performance, allowing early detection of technical or clinical problems concerning pump rotational speed, power consumption, and flow pattern.5 A recent review has demonstrated that tele-health can provide efficient and cost-effective long-term care by improving patient management as well as saving travel expenses.6 Since no experience of an integrated monitoring system for outpatients with VAD has been reported thus far, the present brief report aims to illustrate a web-based application developed in our institution for VAD patient monitoring. At hospital discharge, every patient receives a tablet with a dedicated application for the acquisition of clinical, laboratory, and instrumental data. The application is cross-platform and can be downloaded onto any computer, tablet, or smartphone; it is user friendly, intuitively accessible, and requires the use of username and password, according to current privacy rules. This application allows data sharing, pictures, voice calls, and video chats, that enable health-care professionals to have a real-time assessment of patients, and the patients to have an easier and direct contact with the centre at any time. The 24/7 Help-desk Centre is lead by the VAD coordinator who can deal with most issues, with a cardiac surgeon on-call for further specific concerns. This system allows both a planned follow-up for outpatients and the opportunity to deal with urgent or emergent clinical problems. As regular follow-up, all patients are requested to fill-out, twice a week, the application's modules with instrumental, clinical, and bio-humoral findings. The compilation of these modules is guided and simple; data include body weight, fluid balance, presence of peripheral oedema, international normalized ratio (INR) value, and driveline pictures at skin exit. Additional laboratory data frequently requested are level of haemoglobin, haptoglobin, bilirubin, reticulocytes, and lactate dehydrogenase. A summary of data acquired by telemonitoring is presented in Table 1. When necessary, photos and videos of examinations performed in other hospitals, such as electrocardiograms, echocardiograms, or computed tomography (CT) scans can also be uploaded (Figure 1). The VAD coordinator also performs a daily video call with every patient and vice versa, so patients or caregivers can contact the Help Centre at any time to find a solution to clinical, psycho-social, or technical problems. Furthermore, our dedicated psychologist uses the video chat to offer individual interviews to patients and caregivers. Another useful result was the possibility of remotely controlling the driveline medication, instructing the territorial nursing personnel on how to clean and disinfect the wound, avoiding the need for patient hospitalization. This system has proved to be useful in the case of emergency situations representing an ideal support for caregivers and less experienced clinicians when they have to deal with such a complex patient at home. All these data were properly stored and became part of the medical record of the patients. The ‘Teleconsultation Project’ started in November 2011; 20 patients have been followed and monitored, 18 with a left VAD (LVAD) and 2 with a biventricular VAD. Among them, only eight patients were resident in our region, while the other 12 lived in other regions (in four cases beyond 600 km). During a median telemonitoring follow-up of 135 days (30–1075 days), more than 2000 teleconsultations have been activated: most of them (daily video call, psychological consultations, clinical data examinations, or minor issues) were concluded within 45 min, while in the remaining 15% of cases more clinical complexity required additional examinations (in particular, INR re-evaluation, laboratory blood tests, echocardiograms), multidisciplinary discussion, and medical consultation both in our centre or in a remote hospital. A limited number of complications demanded hospitalization due to driveline or pulmonary infection (n = 10), major or minor stroke (n = 6), heart failure (n = 4), gastrointestinal bleeding (n = 3), arrhythmias (n = 3), pump arrest (n = 1), battery malfunction (n = 1), and controller malfunction (n = 1). On 10 occasions, our Help Centre contributed to solving difficult and urgent problems (VAD malfunction, thromboembolic event, and gastrointestinal bleeding) in a remote hospital. The VAD coordinator and the dedicated surgeon gave advice or indications to patients, caregivers, and physicians of other hospitals. Even if teleconsultations could not solve all possible issues (psychological, mechanical, clinical) remotely, on such occasions telemonitoring has been demonstrated to be a valuable support. Notably, thanks to the constant surveillance and real-time assistance, this application improves hospital continuity of care by early identification and rapid activation to solve clinical problems. Hence, it contributes to a significant reduction in unnecessary hospital re-admissions (estimated reduction of about 30–40% yearly), laboratory tests, and even outpatient visits, translating therefore into a significant reduction in health-care costs. Importantly, an admission in an outpatient clinic costs around 100 Euro, while a 2-day ward admission costs 1500 Euro. While considering an annual total cost of 7000 Euro for server administration (including cloud rental), sensible data encryption, regular maintenance, and evolution of the application, the mean cost of a single teleconsultation is about 5 Euro. The additional cost of nurses and physicians is difficult to estimate since a VAD programme needs human resources to take care of patients after the implantation; however, overall, teleconsultation seems to facilitate better follow-up at a much lower cost. Data on post-cardiac surgery have shown that a trans-telephone guide for ambulatory follow-up reduced the costs associated with re-hospitalization;7 however, there is no cost-effectiveness experience regarding telemedicine in LVAD patients. Moreover, this remote assistance system improves the quality of life of patients by avoiding unnecessary travel and enhancing their perception of being the central part of an integrated care pathway for their self-care and well-being. Telemedicine has been demonstrated to be useful in providing patients with the best medical and scientific information, thereby improving patients' knowledge about their current condition and possibly leading to a better compliance to therapy.6 Our early experience shows that this monitoring and management system achieves encouraging positive feedback in terms of perceived safety, reducing the anxiety for a ‘device-depending survival status’ by daily video calls, as well as hospitalization rate and clinical-problem solving. Furthermore, it provides an overall improvement in the patients' and their families' quality of life. Conflict of interest: none declared.

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