key: cord-308357-sjravgng authors: Mariania, Silvia; Schmittoa, Jan D. title: Out of Hospital Management of LVAD Patients During COVID‐19 Outbreak date: 2020-05-28 journal: Artif Organs DOI: 10.1111/aor.13744 sha: doc_id: 308357 cord_uid: sjravgng Coronavirus disease 2019 (COVID‐19) has been declared a pandemic touching thousands of patients all around the world. Patients supported with left ventricular assist devices (LVADs) are usually affected by long‐standing cardiovascular diseases and subjected to variations of the normal cardiovascular physiology, thus requiring an even closer monitoring during the COVID‐19 outbreak. Nevertheless, the COVID‐19 pandemic led to a drastic reduction of routine clinical activities and a consequent risk of looser connections between LVAD patients and their referring center. Potential deleterious effects of such a situation can be delayed recognition of LVAD‐related complications, misdiagnosis of COVID‐19 and impaired social and psychological well‐being for patents and families. As one of the largest LVAD programs worldwide, we designed a sustainable and enforceable telemonitoring algorithm which can be easily adapted to every LVAD center so to maintain optimal quality of care of LVAD patients during the COVID‐19 pandemic. Coronavirus disease 2019 (COVID-19) has been declared a pandemic affecting thousands of patients all around the world. Patients suffering from cardiovascular comorbidities have been identified as one of the groups exposed to higher morbidity and mortality [1] . A recent meta-analysis including 46,248 Chinese patients demonstrated that the most prevalent comorbidities were hypertension (17±7%, 95% CI 14-22%), diabetes (8±6%, 95% CI 6-11%), and cardiovascular diseases (5±4%, 95% CI 4-7%) [2] . A special population at risk for COVID-19 includes end-stage heart failure (HF) patients and, more specifically, patients supported with left ventricular assist devices (LVADs). These patients are chronically affected by long-standing cardiovascular diseases and are subjected to variations of the normal This article is protected by copyright. All rights reserved cardiovascular physiology due to a non-pulsatile blood flow, exposure of the blood to artificial surfaces and risk of hemorrhagic and thrombotic events. As a consequence, these patients deserve a constant connection to specialized multidisciplinary HF teams, regular visits to outpatient clinic, constant presence of highly trained VAD-coordinators and a 24/7 dedicated hotline. The COVID-19 outbreak led to a drastic reduction of routine clinical activities to create new COVID-19 isolated wards and prioritize COVID-19 patients. Accordingly, also elective LVAD surgeries have been suspended with a potential morbidity and mortality increase in LVAD candidates waiting for implantation. Furthermore, the tight connection between LVAD patients and their referring center risks to be loosened with potential deleterious effects such as delayed recognition of LVAD-related complications, misdiagnosis of COVID-19 and impaired social and psychological well-being for patents and families. In order to avoid such a situation, a specific LVAD management algorithm should be implemented in each LVAD center. On the global scene, Germany represents a positive example with high COVID-19 test rates on the general population and relative low mortality. At the same time, Germany hosts large LVAD programs such as the one at Hannover Medical School which can look back to more than 750 implantations in the past 9 years and serve constantly for about 250 LVAD patients in the follow-up program. Based on this peculiar situation in the global COVID-19 and LVAD scenario, our center developed a specific algorithm for out of hospital management of LVAD recipients during the COVID-19 outbreak. Due to the general re-organization of healthcare resources, elective LVAD implantations have been reduced to allow for a higher availability of intensive care beds. Consequently, only patients classified as INTERMACS profile 1 and 2 are considered for LVAD implantation. In parallel, non-urgent visits to the outpatient clinic and elective hospital admissions have been suspended to reduce the infection risk in HF patients. Healthcare professionals involved in the management of LVAD recipients have been divided in two inhospital working groups which alternate themselves every 7 days. This strategy ensures all basic services for in-hospital patients such as a constant presence of specialized surgeons and cardiologists as well as VAD-coordinators. In turn, this guarantees a lower infection risk for healthcare professionals due to a 50% reduction of their in-hospital working time and provides a constant back-up of healthy personnel in case of infection of a team member [3] . At the same time, the team members working from home can provide a 24/7 dedicated LVAD hotline and are crucial in the telemonitoring organization. This article is protected by copyright. All rights reserved Each LVAD recipient routinely followed-up in the outpatient clinic enters the telemonitoring algorithm Moreover, in order to enter this monitoring program, the patient should be judged as adequately educated through extensive talks and training sessions focused on driveline dressing techniques, battery and controller exchange, blood pressure, fluids and anticoagulation self-management. If the patient is deemed suitable for the telemonitoring program, a VAD-coordinator establishes a COVID-19 specific phone contact. The patient is invited to strictly follow national guidelines in terms of social behaviors and is provided with surgical masks and driveline dressing kits through home delivery. This phone contact has several goals: identify a possible COVID-19 case, rule out LVAD complications, educate the patient on a correct behavior to prevent COVID-19, answer his/her questions and provide psychological support. A specific questionnaire has been designed to investigate COVID-19 symptoms such as fever, chills, increased fatigue, muscle pain, sore throat, anosmia, cough, cold-like symptoms, diarrhea and worsening dyspnea. The questionnaire investigates also possible contacts with COVID-19 cases or flu-like episodes in the last 6 months. At the same time, the VAD-coordinator records all LVADspecific data like flow, speed, power consumption, INR values, weight and status of the driveline site. If deemed necessary, the patient is asked to send a picture of the driveline site through email or smartphone. In case of no evident problems, the VAD-coordinator re-contacts the patient weekly to repeat the full monitoring. If a suspect of COVID-19 is raised, the LVAD patient is referred to a COVID-19 dedicated team while if an LVAD complication is suspected, the patient is transferred to the LVAD clinic. LVAD patients should be considered with special attention during the COVID-19 outbreak due to their high cardiovascular risk and their specific needs. While it is important to prevent COVID-19, the routine care should not be discontinued to avoid severe complications both on clinical and psychological sides. Therefore, specific management algorithm should be implemented by every implanting and referring LVAD center to aim for early diagnosis and treatment of COVID-19 or LVAD complications. A continuous telemonitoring system based on a fully-digitalized structure is desirable [4] [5] [6] [7] , yet not available in every LVAD center. On the other side, our telemonitoring algorithm has been designed to be sustainable, enforceable and adaptable to every LVAD center, regardless of number of LVAD patients or previous experiences. Coronavirus Disease 2019 (COVID-19) and Cardiovascular Disease Prevalence of comorbidities in the novel Wuhan coronavirus (COVID-19) infection: a systematic review and meta-analysis Our thanks to ALL healthcare workers on the frontlines caring for our most vulnerable Accepted Article This article is protected by copyright. All rights reserved Infrastructural needs and expected benefits of telemonitoring in left ventricular assist device therapy: Results of a qualitative study using expert interviews and focus group discussions with patients Initial experience with telemonitoring in left ventricular assist device patients Continuous LVAD monitoring reveals high suction rates in clinically stable outpatients Improved aftercare in LVAD patients: Development and feasibility of a smartphone application as a first step for telemonitoring Figure 1 -Algorithm for out of hospital left ventricular assist device (LVAD) management during COVID-19 outbreak. INR, international normalized ratio; MAP, mean arterial pressure This article is protected by copyright. All rights reserved The authors gratefully acknowledge Mrs. Alexandra Schöde and all VAD-coordinators for their assistance in the design of the presented algorithm. JDS received consultant honoraria from Medtronic and Abbott.