Even under optimal medical treatment, patients with advanced heart failure (HF) have a poor prognosis, with heart transplantation being the preferred treatment. However, access to heart transplantation is limited. To address this, left ventricular assist devices (LVADs) have been introduced as an alternative therapeutic option, either as a bridge to transplantation or as destination therapy. Managing these patients is complex, often leading to serious complications, frequent readmissions, prolonged hospital stays, and high healthcare costs. Therefore, rapid access to advanced units is essential. However, care for LVAD patients is traditionally concentrated in a few specialized implanting centers. 

The implementation of a shared care model (SCM) is defined as the joint involvement of primary care physicians and specialists in the planned care of patients with chronic diseases, coordinated through enhanced information exchange beyond routine hospital discharges and referrals. This allows geographically separated care teams to provide high-quality, patient-centered care through coordinated collaboration. However, when focusing on the management of LVAD patients, evidence supporting these principles is unavailable. The aim of this work is to compile and discuss current scientific evidence on the use of SCMs in the management of LVAD patients. 

This study is a literature review that incorporated two key search elements: LVADs and shared care. The search included all scientific literature written in English and published before June 3, 2023. Out of 1559 records retrieved, five studies were included in the review: four review articles and one prospective study. All articles originated from the United States and were published between 2015 and 2023. 

Five main themes were identified: 

Definition and Objectives: The core of a shared care model is a collaborative approach between the LVAD implanting center and geographically distant, non-implanting care sites. The primary goal is to improve patient satisfaction and quality of life while maintaining LVAD-related clinical outcomes. 

Criteria for Shared Care Partnerships: Key criteria include: 

A multidisciplinary shared care team led by an advanced HF cardiology specialist with expertise in LVADs, supported by advanced practice nursing. 

Approximately 50% of follow-up care provided at the shared care center. 

Use of standardized collaborative protocols. 

Effective communication and collaboration among all SCM members. 

Perceived Benefits: Benefits include enhanced patient satisfaction, improved quality of life, reduced stress for patients and caregivers, and better continuity of care. For the healthcare system, SCMs enable high-quality, patient-centered care while extending services beyond implanting centers. 

Perceived Concerns and Challenges: Issues include a lack of experience at non-implanting centers, the need for continuous staff training, and the potential fragmentation of care. 

Clinical Outcomes: The prospective study included in the review found that the absence of LVAD-specific care was associated with higher rates of mortality, pump thrombosis, and device-related infections. SCMs showed promise in improving patient outcomes but require well-designed communication structures and standardized protocols. 

As the number of LVAD patients grows, SCMs are increasingly necessary to maintain accessible care. While SCMs appear promising, evidence on their clinical impact and their effect on healthcare systems remains limited. Future studies should focus on the prospective evaluation of SCMs to establish standardized, evidence-based protocols. 

COMMENTARY 

The implantation of LVADs is becoming increasingly common in patients with advanced HF, with their care and follow-up predominantly concentrated in specialized tertiary hospitals. However, the growing workload at implanting centers presents significant challenges in providing care to patients residing in remote areas. An emerging approach to managing LVAD patients is the use of a shared care model (SCM), facilitating collaboration between implanting centers and local, non-implanting hospitals. 

This review explores and synthesizes current scientific evidence on the application of SCMs in the management of LVAD patients. This model is defined as a collaboration between the LVAD implanting center and non-implanting centers for continuous patient care. The shared goal is to improve patient satisfaction and quality of life while preserving clinical outcomes associated with LVADs. 

The findings indicate that the primary benefits of SCMs include improved patient satisfaction, contributions to enhanced quality of life, and reduced stress for both patients and caregivers, as well as better continuity of care. At a healthcare system level, SCMs enable the delivery of continuous, high-quality, patient-centered care beyond the boundaries of the implanting center. 

Shared care models generally require the commitment of a multidisciplinary team, supervised by a specialist in advanced HF and LVADs, and coordinated by advanced practice nursing staff, who act as the frontline contact for patients. Training in the basic principles of LVAD care and maintaining clinical competencies are crucial to ensure the delivery of safe, high-quality care. A prospective study included in the review demonstrated that the lack of LVAD-specific care was associated with poorer survival rates and higher incidences of pump thrombosis and infections related to LVADs. 

Additionally, SCMs require a robust communication structure between implanting centers and shared care sites, structured coordination, and the engagement of all involved parties. Follow-up protocols are essential, including standardized guidelines based on prospective studies, to ensure the safe and effective shared care of LVAD patients. 

Future research should prospectively investigate the impact of SCMs on patient outcomes, implanting centers, and shared care sites. Although further evidence is needed, SCMs represent a promising organizational system that should be established as a quality standard in the care of LVAD patients. 

REFERENCE: 

Drost VCE, Otterspoor LC, Zijderhand CF, Sjatskig J, Kluin J, De Boer RA, Caliskan K. Shared care for patients with a left ventricular assist device: a scoping review. Eur J Cardiothorac Surg. 2024 Sep 2;66(3):ezae285. doi: 10.1093/ejcts/ezae285.