Cardionerds: A Cardiology Podcast

Dr. Jenna Skowronski, Dr. Shazli Khan, and Dr. Alix Barnes discuss the involvement of palliative care throughout the heart failure spectrum with Dr. Sarah Chuzi. Audio editing for this episode was performed by CardioNerds Intern, Dr. Julia Marques Fernandes.

In this episode, we discuss utilizing palliative care principles while caring for patients with heart failure, particularly those being considered for advanced therapies. We emphasize utilization of communication frameworks when discussing prognosis and making decisions on pursuing therapies such as palliative inotropes, left ventricular assist devices (LVADs), and heart transplant. Additionally, we discuss when to involve specialty palliative care services. Finally, we highlight the difference between palliative care and hospice and how to help patients navigate the transition from life-prolonging care to hospice.

Dr. Jenna Skowronski is the Chair for the CardioNerds Heart Failure Council. Dr. Jenna Skowronski and Dr. Shazli Khan are the Co-chairs for the CardioNerds Advanced Heart Failure Therapies Series. Dr. Alix Barnes is the CardioNerds FIT Ambassador at UPMC and member of the CardioNerds Critical Care Cardiology Council.

Enjoy this Circulation Paths to Discovery article to learn more about the CardioNerds mission and journey.

US Cardiology Review is now the official journal of CardioNerds! Submit your manuscripts here.

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Pearls

Primary palliative care is care provided by a clinician that is not a palliative care specialist, such as a heart failure clinician having a conversation with a patient about their goals and values in clinic. 

Taking time to get to know a patient as an individual and learning their goals and values prior to diving into conversations about prognosis and change in treatment plan facilitates more effective goals of care discussions.  

Utilizing and practicing a communication framework can improve our skills at goals of care discussions.  

Palliative inotropes should be reserved for patients experiencing symptomatic benefit from the therapy that outweighs the associated risks including arrhythmias and infections. The burden of managing these therapies at home should also be considered.

Partnerships between cardiologists and hospice agencies can improve the experience for patients with heart failure who enroll in hospice. Cardiologists can continue to see their patients even after hospice enrollment and help with symptom management.  

Notes

Notes: Notes drafted by Dr. Barnes.

1. What is the difference between primary palliative care and specialty palliative care?

Primary palliative care is the delivery of palliative care services that any clinician can deliver.

This includes aligning treatment with a patient’s goals and basic symptom management. For heart failure patients, symptom management can include cardiac symptoms such as dyspnea and chest pain as well as managing comorbid mood disorders such as adjustment disorder, depression, and anxiety.

Advanced palliative care skills take additional training and time to develop. These include leading a difficult family meeting, managing symptoms that are not controlled with standard therapies and responding to emotional and spiritual distress. When these situations are encountered, referral to a specialty palliative care service should be considered. 1

2. How is palliative care integrated throughout the disease trajectory of a patient with heart failure?

Heart failure clinicians deliver primary palliative care when assessing a patient’s preferences, goals and values or managing symptoms.

As a patient’s disease progresses, the heart failure team also engages in primary palliative care when delivering news about prognosis.

When advanced therapies are being considered, utilization of shared decision-making (SDM) should be employed (see question 3 for further discussion on SDM).

For patients being considered for LVAD, the Centers for Medicare and Medicaid Services (CMS) mandates that patients are seen by a palliative care specialist prior to implantation. 2

Despite this, there remains variability in how institutions involve specialty palliative care in this decision-making process. Thoughtful consideration of what palliative care resources are available at your institution should guide how best to integrate specialty palliative care teams into the LVAD decision tree.

One example of a model for meeting this mandate is having a small team of heart failure clinicians with additional palliative care training meet all patient’s being evaluate for LVAD.

3. What is shared decision-making (SDM) and how is it utilized when evaluating a patient for advanced therapies?

SDM is a collaborative process where patients and clinicians work together to make medical decisions that are aligned with a patient’s goals and values.3

There are a variety of communication frameworks that can be used to engage in effective SDM.

One framework is the Serious Illness Conversation guide. This is an evidenced based framework that can be used to deliver the news about a patient’s current condition and then assess their goals, values and preferences for next steps in their treatment plan.4  This framework can be helpful when discussing prognosis prior to introducing the idea of an evaluation for advanced therapies.

REMAP is a second commonly used framework which stands for Reframe, Expect Emotion, Map What’s Important, Align, and Plan.5 This framework is similarly helpful when starting a discussion about advanced therapies with a patient.

Both frameworks prioritize learning about a patient’s goals, values, and preferences prior to making a recommendation for a treatment plan. Listening more than speaking and accepting that a patient and their family may choose a path that is different than what you personally might choose for yourself or your loved ones are vital pillars to engaging in these conversations effectively.

When discussing LVAD, it is important to avoid framing the decision as “LVAD or no LVAD,” rather LVAD versus best supportive care.

The “Best Case, Worst Case” framework is an effective way to create choice awareness for patients when they are faced with making this decision. This is a way to discuss both the best outcomes after LVAD implantation as well as the potential complications so a patient is better able to understand the full spectrum of possible outcomes. 6

4. How do you select which patients would benefit from home inotrope therapy?

There is no data demonstrating a survival benefit with use of palliative inotropes. There may be subsets of patients who derive a survival benefit, such as patients whose renal function worsens when the agent is withdrawn, however there is no concrete data proving this. 7

Therefore, the benefit of home inotrope therapy should be based on if the patient derives symptomatic benefit from these agents. Additionally, risks of the therapy such as arrhythmias and infection as well as the burden of managing these therapies at home should also be weighed in the decision.8

Life expectancy for patients being initiated on palliative inotropes likely ranges from 6 to 9 months. Given this prognosis, concordant palliative care efforts should be intensified when starting patients on these agents. This can either be through involvement in specialty palliative care or increasing primary palliative care interventions. 9

5. How do you determine if a patient would be a candidate for hospice and how do you discuss hospice with patients and their families?

Hospice is a comprehensive program that provides supportive care to patients at end of life. This includes a team of physicians, nurses, aids, social workers and chaplains that can deliver care in the home, at a nursing facility, or in an inpatient hospice facility. 10

Patients with a prognosis of 6 months or less can qualify for hospice services.

Even if a patient qualifies for hospice based on their prognosis, it is important to assess if a patient’s goals and values align with hospice. Introducing hospice to patients who still desire life prolonging care can cause mistrust between the patient and their health care team.

When introducing hospice, it is helpful to describe the services hospice offers in addition to naming the service as some patients may have a negative connotation with the word “hospice.”

6. How can cardiologists partner with hospice agencies to provide better care for these patients?

Heart failure specialists can continue to see their patients even after they enroll in hospice. Partnering in hospice agencies in this way can help improve symptom management for patients while also allowing them to continue meaningful relationships with providers with whom they’ve developed a longitudinal relationship with.

Guideline directed medical therapy (GDMT) and diuretics can be continued while enrolled in hospice as long as they are offering symptomatic benefit. Heart failure specialists can help with adjusting GDMT to cheaper formulations, such as exchanging angiotensin receptor-neprilysin inhibitors (ANRIs) for angiotensin receptor blockers (ARBs).

Many hospice agencies cannot accept patients receiving palliative inotropes due to the resources and training required to safely care for these patients. Understanding what hospice agencies in your area can and cannot support allows heart failure specialists to have informed discussions with patients and make appropriate referrals.

References

Quill TE, Abernethy AP. Generalist plus Specialist Palliative Care — Creating a More Sustainable Model. N Engl J Med. 2013;368(13):1173-1175. doi:10.1056/NEJMp1215620. https://www.nejm.org/doi/full/10.1056/NEJMp1215620

Ventricular Assist Devices for Bridge-to-Transplant and Destination Therapy. Published online August 1, 2013. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&NCAId=268

Godfrey S, Barnes A, Gao J, Katz JN, Chuzi S. Shared Decision-making in Palliative and End‑of‑life Care in the Cardiac Intensive Care Unit. US Cardiol Rev. 2024;18:e13. doi:10.15420/usc.2024.03. https://pubmed.ncbi.nlm.nih.gov/39494405/

Baxter R, Pusa S, Andersson S, Fromme EK, Paladino J, Sandgren A. Core elements of serious illness conversations: an integrative systematic review. BMJ Support Palliat Care. 2024;14(e3):e2268-e2279. doi:10.1136/spcare-2023-004163. https://pmc.ncbi.nlm.nih.gov/articles/PMC11671901/

Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: A Framework for Goals of Care Conversations. J Oncol Pract. 2017;13(10):e844-e850. doi:10.1200/JOP.2016.018796. https://ascopubs.org/doi/10.1200/JOP.2016.018796

Kruser JM, Nabozny MJ, Steffens NM, et al. “Best Case/Worst Case”: Qualitative Evaluation of a Novel Communication Tool for Difficult in-the-Moment Surgical Decisions. J Am Geriatr Soc. 2015;63(9):1805-1811. doi:10.1111/jgs.13615. https://pmc.ncbi.nlm.nih.gov/articles/PMC4747100/

Tolia S, Khan M, Khan S, et al. Mortality and long-term outcomes of palliative inotropes in ischemic and non-ischemic cardiomyopathy. Eur Heart J.  2021;42(Supplement_1):ehab724.0915. doi:10.1093/eurheartj/ehab724.0915. https://academic.oup.com/eurheartj/article/42/Supplement_1/ehab724.0915/6392681

Chuzi S, Allen LA, Dunlay SM, Warraich HJ. Palliative Inotrope Therapy: A Narrative Review. JAMA Cardiol. 2019;4(8):815. doi:10.1001/jamacardio.2019.2081. https://jamanetwork.com/journals/jamacardiology/article-abstract/2737414#google_vignette

Chuzi S, Gao J, Thariath J, et al. Characteristics and Outcomes of Palliative Continuous Intravenous Inotrope Support Among Medicare Beneficiaries With Heart Failure. J Am Heart Assoc. 2025;14(14):e039397. doi:10.1161/JAHA.124.039397. https://www.ahajournals.org/doi/10.1161/JAHA.124.039397

What is hospice? Published online September 24, 2024. https://hospicefoundation.org/what-is-hospice/

CardioNerds (Dr. Hamza Patel, Dr. Jenna Skowronski, and Dr. Apoorva Gangavelli) discuss advanced heart failure and LVAD management with Dr. Mark Belkin, Advanced Heart Failure & Transplant Cardiologist, and Dr. Chris Salerno, Cardiothoracic Surgeon. They explore the nuances of right ventricular (RV) physiology, perioperative hemodynamic optimization, long-term complications, sensitization and transplant considerations, and the evolving role of GDMT in LVAD patients.  This episode highlights the delicate interplay between surgical and medical management in achieving optimal outcomes for patients living with durable mechanical circulatory support.Audio editing by CardioNerds Academy intern, student doctor, Pace Wetstein.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

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Pearls

“The right ventricle sets the stage.” — LVAD success hinges on RV performance; a struggling RV can turn a perfect LVAD surgery into a perfect storm. 

“Watch the ratios.” — A PAPi < 2 and RA:PCWP >0.6 signal high risk for RV failure post-implant; trends and response to optimization matter more than static numbers. 

“From hemocompatibility to hemodynamics.” — The LVAD field has moved from fighting pump thrombosis to mastering long-term RV failure and aortic insufficiency. 

“Not all antibodies are created equal.” — LVAD-related sensitization often resolves post-transplant, reminding clinicians to interpret PRA trends in context. 

“Recovery is possible.” — The RESTAGE-HF trial and emerging SGLT2 data hint at a new era: not just sustaining life with LVADs but restoring native heart function. 

Notes

Notes drafted by Dr. Hamza Patel.

1. Hemodynamic & Vasoactive Management of the RV 

Use norepinephrine and vasopressin for pressor support; consider dobutamine as inotrope of choice. 

Consider avoiding early milrinone due to hypotension and reduced coronary perfusion. 

Use inhaled NO or epoprostenol selectively; institutional variation depends on cost and supply. 

Key hemodynamic markers: 

PAPi = (PA systolic – PA diastolic) / RA pressure. 

PAPi < 2 → increased RV failure risk. 

RA:PCWP ratio ≈ 0.6 normal; ≈ 1 → severe RV dysfunction. 

RV reserve—the ability to improve these indices with optimization—is a stronger predictor of outcomes than baseline numbers alone. 

NOTE: there is no robust data to guide vasoactive medical decision-making and there is substantial institutional variability in practive. 

2. Long-Term LVAD Complications 

MOMENTUM 3 trial: HeartMate 3 reduced pump thrombosis (10 → 1 %), stroke (14 → 5%), and GI bleed (77 → 43 %). 

Persistent issues: driveline infections, RV failure, and aortic insufficiency. 

Driveline care: silver sulfadiazine (Silvadene) cream linked to lower infection rates (Cowher & Kenmore 2025). 

Field now focuses on hemodynamic-related adverse events—the next frontier in LVAD outcomes. 

Innovation ahead: smaller drivelines and fully implantable LVADs to eliminate infection risk. 

3. Sensitization and Transplant Candidacy 

LVADs may induce de novo HLA antibodies, complicating transplant matching. 

These antibodies tend to be transient and less cytotoxic, often resolving post-transplant. 

Sensitization degree varies by device and patient; management strategies are center-dependent. 

The field is redefining which antibodies are truly LVAD-induced versus incidental. 

4. GDMT & Myocardial Recovery 

GDMT data in LVAD patients limited—excluded from major HFrEF trials. 

RESTAGE-HF: aggressive GDMT post-LVAD yielded 52% explant rate within 18 months. 

SGLT2 inhibitors: emerging evidence of reverse remodeling and reduced LV size (Belkin et al., THT 2025). 

GDMT promotes recovery but requires cautious titration to avoid hypotension and RV strain. 

5. Future of LVAD Therapy 

The fully implantable LVAD remains the goal—wireless energy, no driveline, and fewer infections. 

Short-term focus: device miniaturization, improved energy efficiency, and better hemocompatibility. 

HeartMate 3 remains gold standard until next-generation systems mature. 

References

Mehra MR et al. NEJM 2018 — MOMENTUM 3 Final Report. 

Takeda K et al. JHLT 2020 — Predictors of RV Failure After LVAD. 

Imamura T et al. Circ Heart Fail 2017 — Hemodynamics and RV Adaptation Post-LVAD. 

RESTAGE-HF Trial, JHLT 2019. 

Cowher J, Kenmore C et al. 2025 — Driveline Care & Infection Outcomes. 

Belkin M et al. THT 2025 — SGLT2 Inhibition and Reverse Remodeling Post-LVAD.

This inaugural episode of the CardioNerds Pulmonary Embolism (PE) Series explores the evolution of acute PE care. Dr. Ibrahim Zahid, Dr. Dinu Balanescu, and Dr. Billy Joe Mullinax join guest expert Dr. Kenneth Rosenfield to discuss the shifting landscape of PE management.

Pulmonary embolism (PE) remains a leading cause of cardiovascular mortality and a frequent diagnostic challenge, often masquerading as myocardial infarction or a benign illness. Over the past decade, PE care has evolved from anticoagulation-only strategies to nuanced, risk-stratified, multidisciplinary management. Modern approaches integrate hemodynamics, biomarkers, and advanced imaging to guide therapy, including catheter-directed interventions and large-bore thrombectomy. The Pulmonary Embolism Response Team (PERT) model addresses historical gaps by coordinating rapid, multispecialty decision-making and standardizing care pathways. The PERT Consortium further advances PE care through education, research, and the world’s largest PE registry, while fostering leadership and research opportunities for trainees. Despite advances, long-term outcomes and post-PE syndromes remain important areas for future investigation. Audio editing by CardioNerds Academy intern, student doctor, Pace Wetstein.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

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Pearls

PE is a “master masquerader”—maintain suspicion for atypical presentations like myocardial infarction, heart failure, flu, or anxiety.

Multidisciplinary management mediated through pulmonary embolism response teams improves outcomes and standardizes care.

Risk stratification integrates hemodynamics, biomarkers, and imaging.

Advanced therapies have expanded beyond anticoagulation.

Long‑term follow‑up and post‑PE syndrome need more research.

Notes

Notes: Notes drafted by Dr. Ibrahim Zahid.

1. How has the clinical approach to PE changed over the past decade?

PE is the third leading cause of cardiovascular death and historically under‑recognized.

Symptoms mimic MI, HF, asthma, syncope, and more.PE is a silent killer, and it should be recognized more as a cause of spontaneous cardiac arrest.

Where life threatening disease like stroke which is owned by neurological specialists and MI is primarily managed by cardiac specialists, PE is an entity without a professional home. The PERT Consortium brings the specialties together for PE care.

2. Ten years ago, a 58-year-old patient with a large bilateral PE, RV dilation, and positive biomarkers might have been managed with anticoagulation and close observation alone. Today, with evolving—but still uneven—data on advanced therapies, PE care feels far more nuanced and highly dependent on where you practice. What are the major gaps in traditional PE management that clinicians should recognize, and what care pathways should they be aware of across different hospital systems?

Care has shifted from anticoagulation‑only to multidisciplinary approaches like catheter directed thrombectomy.

Risk‑based pathways and the use of CT angiogram has improved early recognition. Risk stratification tools must be used as tools for early recognition of intermediate risk PE.

Untreated PE leads to chronic complications like chronic thromboembolic disease and chronic thromboembolic pulmonary hypertension, which requires long term clinic follow up.

3. What is the role of risk stratification tools such as PeSI, sPeSI scores, cardiac biomarkers, and imaging findings in PE, and how do they guide treatment decisions in real world practice?

Integrate vitals (blood pressure and heart rate), biomarkers (troponin, pro-BNP), RV/LV ratio assessment, acid‑base status, and scores.

Tools include PESI, sPESI, BOVA, HESTIA, FAST, Geneva, NEWS, shock index.

Vitals, lactate, acid-base status, and tools like NEWS or shock index track clinical evolution.

PESI/sPESI estimate 30-day mortality and help identify low-risk patients who may be candidates for early discharge or outpatient therapy.

Clinical judgment matters—scores don’t fully capture clot burden, trajectory, or bleeding risk.

4. How was the pulmonary embolism response team created, and since its creation, what evidence or outcome data became available to support the PERT model?

Originated after a sentinel case at MGH: A young, pregnant woman in her 30s, who collapsed at home, underwent thrombectomy, and had to be on ECMO for a few days. The case brought cardiology, cardiac surgeons and critical care physicians together for planning and improvement in her health, which was rewarding.

Thereby, it was decided to bring specialties involved in PE care together to create a response team.

The name of the team, Pulmonary Embolism Response Team (PERT), was coined by Richard Channick in the first meeting.

Posters were set up all over the hospital to call a centralized line when an acute PE is recognized

A meeting was held to present the concept of putting together a consortium, with development of action items and a PERT database.

Enabled rapid multidisciplinary input using early teleconferencing tools.

5. Given concerns about having too many ‘cooks in the kitchen’ during the initial PE call—especially with rotating teams—how can institutions reconcile workflow complexity with standardized pathways in a way that meaningfully supports and justifies the added burden on frontline clinicians?

Every hospital’s PERT is different, catering to their needs and workflow

At least two disciplines are needed to make a PERTData is currently being collected to guide further on how the workflow can be standardized

Most importantly, the team brings in resources that were not available prior to PERT formation.

6. What are the main goals of the PERT consortium, and how does it support clinicians and institutions involved?

To improve care and improve outcomes for patients with PE

Expand education, refine algorithms, standardize care with Centers of Excellence.

Maintain the largest PE registry for research and outcomes improvement.

7. Beyond global networking, shared learning from successful systems, and the pathway toward Center of Excellence designation, what additional benefits can clinicians and health systems gain by participating in the PERT Consortium?

The ability to learn from other systems, the ability to share experiences.

Allow people to develop their professional careers like leadership experience, becoming a member of the trainee council

Initiate projects and receive funding for your ideas

8. For trainees interested in pulmonary embolism care, how can a trainee be a champion at their institution? Does PERT provide assistance and how can they really contribute meaningfully even before becoming a fellow/attending?

Medical students and residents interested in PE should reach out to the consortium and the consortium will hook you up with the correct mentors who can nurture you along.

Listen to the podcasts.

Participate with your local PERT team

PERT wants involvement of people who are social media savvy to help spread the word on PE.

Top three take-away points from this episode

Acute PE care has advanced and multiple treatment modalities for acute PE including catheter directed therapy, large bore thrombectomy, are becoming standard of care.

Multidisciplinary models like PERT improve coordination and outcomes.

Trainees play a vital role in advancing PE care through involvement, research, and education

References

Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020 Jan 21;41(4):543-603. doi: 10.1093/eurheartj/ehz405. PMID: 31504429. https://pubmed.ncbi.nlm.nih.gov/31504429/

Rosovsky R, Zhao K, Sista A, Rivera-Lebron B, Kabrhel C. Pulmonary embolism response teams: Purpose, evidence for efficacy, and future research directions. Res Pract Thromb Haemost. 2019 Jun 9;3(3):315-330. doi: 10.1002/rth2.12216. PMID: 31294318; PMCID: PMC6611377. https://pmc.ncbi.nlm.nih.gov/articles/PMC6611377/

Rosenfield K, Bowers TR, Barnett CF, Davis GA, Giri J, Horowitz JM, Huisman MV, Hunt BJ, Keeling B, Kline JA, Klok FA, Konstantinides SV, Lanno MT, Lookstein R, Moriarty JM, Ní Áinle F, Reed JL, Rosovsky RP, Royce SM, Secemsky EA, Sharp ASP, Sista AK, Smith RE, Wells P, Yang J, Whatley EM; Pulmonary Embolism Research Collaborative (PERC) Attendees. Standardized Data Elements for Patients With Acute Pulmonary Embolism: A Consensus Report From the Pulmonary Embolism Research Collaborative. Circulation. 2024 Oct;150(14):1140-1150. doi: 10.1161/CIRCULATIONAHA.124.067482. Epub 2024 Sep 12. PMID: 39263752; PMCID: PMC11698503. https://pubmed.ncbi.nlm.nih.gov/39263752/

Sharifi M, Awdisho A, Schroeder B, Jiménez J, Iyer P, Bay C. Retrospective comparison of ultrasound facilitated catheter-directed thrombolysis and systemically administered half-dose thrombolysis in treatment of pulmonary embolism. Vasc Med. 2019 Apr;24(2):103-109. doi: 10.1177/1358863X18824159. Epub 2019 Mar 5. PMID: 30834822. https://pubmed.ncbi.nlm.nih.gov/30834822/

Pandya V, Chandra AA, Scotti A, Assafin M, Schenone AL, Latib A, Slipczuk L, Khaliq A. Evolution of Pulmonary Embolism Response Teams in the United States: A Review of the Literature. J Clin Med. 2024 Jul 8;13(13):3984. doi: 10.3390/jcm13133984. PMID: 38999548; PMCID: PMC11242386. https://pubmed.ncbi.nlm.nih.gov/38999548/

Rivera-Lebron B., McDaniel M., Ahrar K., Alrifai A., Dudzinski D.M., Fanola C., Blais D., Janicke D., Melamed R., Mohrien K., et al. Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium. Clin. Appl. Thromb. Hemost. 2019;25:1076029619853037. doi: 10.1177/1076029619853037.
https://pubmed.ncbi.nlm.nih.gov/31185730/

CardioNerds (Dr. Jenna Skowronski [Heart Failure Council Chair], Dr. Shazli Khan, and Dr. Josh Longinow) are joined by renowned leaders in the field of AHFTC (Advanced Heart Failure and Transplant Cardiology) and mechanical circulatory support, Dr. Jeff Teuteberg and Dr. Mani Daneshmand to continue the discussion of advanced heart failure therapies by taking a deep dive into the world of durable LVADs (Left Ventricular Assist Devices). In this episode, we will review the history of ventricular assist devices, the basics of LVAD function, selection criteria for LVAD therapy, and surgical nuances of LVAD implantation. Audio Editing by CardioNerds intern, Joshua Khorsandi.

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

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Pearls

There have been significant advances in the field of MCS/LVAD therapy since the first implanted LVAD in the 1960s, to the first FDA approved device in the early 2000’s, to now the HM3 LVAD, with the most important change being a centrifugal flow/magnetically levitated design that led to minimized hemocompatibility-related adverse events (HRAE’s) (MOMENTUM 3 trial comparing HM2 and HM3). 

The REMATCH trial in 2001 was a pivotal trial for LVAD therapy, demonstrating that in a population of patients with advanced HF (70% IV inotrope dependent), LVAD therapy significantly improved survival at both 1 and 2 years as compared to medical therapy alone.   

MOMENTUM 3 trial was a landmark trial for the HM3 device, showing that in a population of end stage HF patients (86% inotrope dependent, 32% INTERMACS 1-2, and 60% DT strategy), 5-year survival with HM3 was 58% and HM3 had lower HRAE’s compared with HM2. 

There are both patient-specific factors and surgical considerations when it comes to candidacy for LVAD therapy. 

RV function prior to LVAD is a key determinant for success post-LVAD 

Many patients being considered for LVAD may not have robust RV function, however, predicting RV failure after LVAD is exceedingly difficult.  

In general, it doesn’t matter how bad the RV may look on imaging; we care more about the pre-LVAD hemodynamics (look at the PAPi and RA/wedge ratio).  

What happens in the OR may be the most important determinant of how the RV will do with the LVAD! 

Notes

Notes drafted by Dr. Josh Longinow. 

1. Historical background of heart pumps and LVADs 

LVAD Evolution  

FDA approval year 
2001 
2008 
2012 
2017 

Pump 
HeartMate XVE  
HeartMate II 
Heartware HVAD 
HeartMate III 

Flow/Design Features 
Pulsatile Technology  
Continuous flow Axial design 
Continuous flow  Centrifugal design 
Continuous flow   Full MagLev + Centrifugal design 

The 1960’s ushered in the first ‘LVADs’, when the first air-powered ‘LVAD’ was implanted. It kept the patient alive for four days before the patient expired.  

The first generation of LVADs were pulsatile pumps  

The first nationally recognized, FDA approved LVAD was the HeartMate XVE (late 1990s to early 2000s, REMATCH trial). The XVE pump used compressed air (pneumatically driven) to power the pump.  

Prior to the XVE, OHT was the standard of care for patients with advanced, end-stage heart failure.  

The second and third generations of LVADs were non-pulsatile, continuous flow devices and included the HVAD, HM2, and HM3 devices.  

MOMENTUM 3 was a landmark trial for the HM3 device, showing that in a population of sick patients with end stage HF (86% inotrope dependent, 32% INTERMACS 1-2, and 60% DT strategy), 5-year survival with HM3 was 58% and HM3 had lower HRAE’s compared with HM2.  

The only pump that is currently FDA approved for implant is the HM3, although other pumps are in clinical trials (BrioVAD system, INNOVATE Trial). 

2. What are LVADs, and how do they work?  

In simplest terms, the LVAD is a heart pump comprised of several key mechanistic components:  

Inflow cannula 

Mechanical pump  

Outflow cannula 

Driveline 

Controller/Power source 

The HM3 differs from its predecessors (HM2 and HVAD) in several key ways;  

HM3 is placed intrapericardial whereas the HM2 was placed pre-peritoneal.  

Perhaps most importantly, the HM3 is a fully magnetically levitated, centrifugal flow pump, whereas the HM2 is an axial flow device. 

Axial flow pumps are not magnetically levitated, leading to more friction produced between the ruby bearing’s contact with the pump rotors, and higher rates of hemocompatibility related adverse events (HRAEs, i.e. pump thrombosis) and the HM2 was ultimately discontinued in favor of the HM3 (MOMENTUM 3 trial). 

3. What do the terms ‘Destination Therapy’ (DT) or ‘Bridge to Transplant’ (BTT) mean when it comes to LVADs?  

When LVADs first came on the stage, EVERYONE was a BTT; these early pumps weren’t designed for long term use (I.e. REMATCH Trial, Heartmate XVE) 

Destination therapy means the LVAD was placed in leu of transplant because there are contraindications to transplant  

REMATCH trial brought about the concept of “Destination therapy”, comparing outcomes in patients (with contraindications for transplant) who received an LVAD vs optimal medical therapy 

Bridge to transplant means we are placing the LVAD in a patient who may not be a transplant candidate at this moment in time (is too sick, or conversely, not sick enough), but may be down the line  

Bridge to recovery is another term used when the LVAD is being placed for a patient we think may have a recoverable cardiomyopathy 

4. What are some factors we should consider when assessing a patient’s candidacy for LVAD, in general, and from a surgical perspective?  

Patient factors  

Older age might push us towards thinking LVAD rather than transplant 

In general, age > 70 is the cutoff for transplant, but this is not a hard cut off and varies institution to institution   

In general, think about things that help predict recovery after a major surgery; Frailty and Nutritional status are important, we try to optimize these prior to LVAD implant  

Right ventricular function remains the Achilles heel of LV support 

We know that needing temporary RV support post LVAD puts you on a different survival curve than patients who don’t need RVAD support 

Studies have not been able to successfully predict who will develop RV failure after LVAD implantation 

What happens in the time between when the patient goes to the OR and when they get back to the ICU is an important determinant who might develop RV failure post LVAD  

Surgical techniques such as implanting the HM3 in the intra-thoracic cavity, rather than intra-pericardial may help maintain LV/RV geometry to help optimize the RV post LVAD  

Surgical considerations for LVAD candidacy 

Small, hypertrophied LV: HM3 inflow cannula is small, but small hypertrophied ventricles tend towards chamber collapse during systole causing suction, needing to run slower with lower flow rates 

Chest size/diameter: pumps have gotten so small now, that for adults, these have become less of a consideration 

BMI: low BMI used to be more of a concern with the older pumps due to where they were placed, and the relative size of the pump itself, not so much now with the smaller HM 3 pumps 

Calcified LV apex: would increase risk of stroke, bleeding  

Driveline tunneling becomes a concern in the super obese population, higher risk for driveline infections (might tunnel these driveline’s shorter, and to a less fatty region of the abdomen, could even tunnel out the thoracic cavity in the super obese to limit skin motion)   

5. Is there a role for MCS (i.e. temporary LVAD such as Impella) in pre-habilitation of patients prior to LVAD surgery?  

The theory of being able to improve systemic perfusion, decongest the organs, and make the patient feel better prior to surgery makes sense, but becomes problematic due to the lack of a hard end point/time for prehabilitation which might risk delays in surgery  

More likely that it can lead to delay in the surgery, with less-than-optimal benefit; you don’t want to prolong the wait for surgery and increase the risk for complications prior to surgery   

An Impella 5.5 is currently FDA approved for 2 weeks of support, not 2 months so timing is important to keep in mind 

It’s unlikely that you will take a patient and convert them from a malnourished, cachectic person in 2 weeks’ time  

6. Is there a role for LVAD therapy in the younger patient population? Should we be thinking of LVAD up front for these patients, with the goal of transplanting down the line?  

Recovery may be more likely in certain populations, particularly younger females with smaller LV’s; in those populations, perhaps bridge to recovery should be the focus, optimizing them on GDMT etc.  

The replacement of transplant, with MCS (LVAD) in young patients has become a topic of discussion, because these pumps have become better and better, with the thinking that an LVAD could bridge a patient for 10 years or so, and they could get a transplant later  

It is still a big unknown, but several concerns exist 

Patients who get LVADs might end up with complications that become contraindication to transplant down the line (stroke, sensitization etc)  

Patients and providers are more hesitant because of the more recent iteration for the UNOS criteria for OHT listing which no longer gives patients with an uncomplicated LVAD higher priority, and therefore they could end up waiting a longer time for a heart after undergoing LVAD 

References

Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001;345(20):1435-1443. doi:10.1056/NEJMoa012175 

Mehra MR, Uriel N, Naka Y, et al. A Fully Magnetically Levitated Left Ventricular Assist Device – Final Report. N Engl J Med. 2019;380(17):1618-1627. doi:10.1056/NEJMoa1900486 

Mancini D, Colombo PC. Left Ventricular Assist Devices: A Rapidly Evolving Alternative to Transplant. J Am Coll Cardiol. 2015;65(23):2542-2555. doi:10.1016/j.jacc.2015.04.039 

Mehra MR, Goldstein DJ, Cleveland JC, et al. Five-Year Outcomes in Patients With Fully Magnetically Levitated vs Axial-Flow Left Ventricular Assist Devices in the MOMENTUM 3 Randomized Trial. JAMA. 2022;328(12):1233-1242. doi:10.1001/jama.2022.16197 

Rose EA, Moskowitz AJ, Packer M, et al. The REMATCH trial: rationale, design, and end points. Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure. Ann Thorac Surg. 1999;67(3):723-730. doi:10.1016/s0003-4975(99)00042-9 

Kittleson MM, Shah P, Lala A, et al. INTERMACS profiles and outcomes of ambulatory advanced heart failure patients: A report from the REVIVAL Registry. J Heart Lung Transplant. 2020;39(1):16-26. doi:10.1016/j.healun.2019.08.017 

Mehra MR, Netuka I, Uriel N, et al. Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure: The ARIES-HM3 Randomized Clinical Trial. JAMA. 2023;330(22):2171-2181. doi:10.1001/jama.2023.23204 

Mehra MR, Nayak A, Morris AA, et al. Prediction of Survival After Implantation of a Fully Magnetically Levitated Left Ventricular Assist Device. JACC Heart Fail. 2022;10(12):948-959. doi:10.1016/j.jchf.2022.08.002 

Bhardwaj A, Salas de Armas IA, Bergeron A, et al. Prehabilitation Maximizing Functional Mobility in Patients With Cardiogenic Shock Supported on Axillary Impella. ASAIO J. 2024;70(8):661-666. doi:10.1097/MAT.0000000000002170 

CardioNerds (Dr. Ramy Doss, Dr. Kelly Arps, and Dr. Naima Maqsood) dive into the nuances of atrial fibrillation (AF) ablation with Dr. Jon Piccini. They provide a high-yield overview of AF ablation, guiding listeners from patient selection through post-procedural management. We review appropriate candidacy for catheter ablation across AF phenotypes, key elements of pre-procedural evaluation including imaging and anticoagulation strategy, and the fundamental procedural steps with pulmonary vein isolation as the cornerstone. The discussion compares lesion set strategies in de novo ablation and reviews currently used energy sources—including radiofrequency, cryoablation, and pulsed-field ablation—highlighting differences in safety and efficacy. They also examine surgical and hybrid approaches for selected patients and outline essential components of post-ablation care, including rhythm monitoring, anticoagulation decisions, and management of complications. This episode integrates contemporary evidence with practical insights to support clinicians delivering comprehensive AF ablation care. Audio editing for this episode was performed by CardioNerds intern Dr. Bhavya Shah.

NOTE: This episode was recorded in March 2025. Since then, the OCEAN trial showed that among patients who had had successful catheter ablation for atrial fibrillation at least 1 year earlier and had risk factors for stroke, treatment with rivaroxaban did not result in a significantly lower incidence of a composite of stroke, systemic embolism, or new covert embolic stroke than treatment with aspirin. 

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

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PEARLS 

Pulmonary veins (PVs) are the dominant triggers in early AF due to their unique myocardial sleeve electrophysiology.  

Pulmonary vein isolation (PVI) remains the cornerstone of AF ablation by blocking PV triggers from reaching the left atrium. Posterior wall isolation is sometimes performed in persistent AFib, but large RCTs found no significant benefit over PVI alone. 

Paroxysmal AF has the highest ablation success rates.  Left atrial health remains the major determinant of outcome. 

Ablation modalities include pulsed field ablation, radiofrequency ablation, and cryo-balloon ablation. PFA offers advantage of relative myocardial selectivity with near zero risk of atrio-esophageal fistula. 

Long-term anticoagulation decisions after ablation currently depend on CHA₂DS₂-VASc score. Recent evidence suggests the safety of stopping anticoagulation in low-risk patients after ablation. 

Early atrial arrhythmia recurrence during a blanking period after ablation (≤3 months) often reflects inflammation — not procedural failure. Late recurrence suggests PV reconnection or residual substrate and often requires repeat ablation.  

Hybrid surgical and catheter Afib ablation represent an aggressive strategy for rhythm control in patients with persistent or long-standing persistent AF with extensive substrate and/or patients who have had multiple failed catheter ablations. 

Notes

1. What is the mechanism behind AF initiation?

Atrial fibrillation (AF) is a progressive condition.

Early AF is primarily trigger-driven, most commonly from the pulmonary veins.

Pulmonary vein myocardial sleeves have unique electrophysiologic properties that promote premature beats and afterdepolarizations.

As AF progresses, atrial remodeling (fibrosis and scar) leads to a more substrate-driven arrhythmia.

2. How does early catheter ablation for atrial fibrillation work?

Electrical Isolation of pulmonary veins, blocking PV triggers from reaching the left atrium.

By reducing burden of atrial fibrillation, this may slow adverse atrial remodeling.

3. Which patients are good candidates for Afib ablation?

Functional Status: ambulatory, active patients derive the greatest benefit. Advanced frailty or severe end-stage cardiovascular disease reduces expected benefit.

Comorbidity Burden: CHA₂DS₂-VASc score helps risk-stratify not only stroke risk but also rhythm-control outcomes.

Type and Duration of AF

Paroxysmal AF → highest likelihood of success (burden reduction often 95–99%).

Long-standing persistent AF → lower suppression rates (often 50–80%).

Left Atrial Health: a major determinant of outcomes.

LA diameter >5.5 cm associated with significantly worse outcomes.

LA volume index (normal ≤34 mL/m²) is preferred over diameter for assessment.

4. What are the predictors of complications from AFib ablation procedures?

Low and high body mass index (BMI)

Chronic corticosteroid use

Severe enlargement of other cardiac chambers

Female gender is associated with a numerically higher risk of complications.

5. Role of preprocedural imaging with cardiac CT or MRI

Cardiac CT

Faster and convenient

Help define LA geometry and Pulmonary vein anatomy

Anatomic Variants as Right middle pulmonary vein, accessory pulmonary veins common pulmonary vein ostium, Atrial diverticula or Accessory left atrial appendage

Consider Cardiac MRI when:

Strong family history of atrial fibrillation or cardiomyopathy

Suspicion of occult structural heart disease

6. Key Procedural Steps in AF Ablation

There is significant variation across centers in anesthesia, mapping, and ablation strategies.

The following outline reflects a common contemporary approach.

Anesthesia & Monitoring

Most commonly performed under general anesthesia.

Benefits include improved catheter stability, enhanced patient comfort, and controlled ventilation (e.g., low-volume, high-frequency).

Invasive arterial line (A-line) is preferred for rapid detection of hypotension.

Vascular Access

Ultrasound-guided femoral venous access with multiple sheaths.

Micropuncture technique is ideal to minimize complications.

Intracardiac Echocardiography (ICE)

ICE catheter insertion.

Reduces complications, guides transseptal puncture, assesses catheter contact, and monitors for pericardial effusion.

Anticoagulation

Systemic heparin initiated before or immediately after transseptal access.

Activated clotting time (ACT) maintained in therapeutic range (typically >300 seconds).

Transseptal Puncture

Access to the left atrium via transseptal sheath.

Often uses electrocautery-assisted wire, with ICE guidance to improve safety.

Left Atrial Mapping

Creation of electroanatomic map (common in many centers).

Ideally performed in sinus rhythm.

Assesses left atrial geometry, voltage (for scar/substrate), and activation timing.

Ablation Strategy

Core component is pulmonary vein isolation (PVI).

Technology options include pulse field ablation (PFA), radiofrequency ablation, and cryoballoon ablation.

Additional ablation (case-dependent):

Posterior wall isolation

Targeting non-pulmonary vein triggers

Linear lesions

Ablation of organized atrial tachycardias/flutters

Emerging approaches include AI-guided strategies.

Post-Ablation Assessment

Confirm pulmonary vein entrance and exit block.

Remap left atrium (in many practices) to evaluate lesion completeness.

Check for complications (e.g., ICE assessment for pericardial effusion).

7. What is Electroanatomic Mapping?

Combines 3D geometry (anatomic reconstruction of cardiac chamber) with electrophysiology (electrical signals from tissue).

How it works:

Mapping catheter is moved along the atrial wall

Records electrograms

System generates:

3D chamber model

Voltage map (tissue health/scar)

Activation map (depolarization timing)

Key information provided

Voltage map (substrate assessment):

High voltage = healthy tissue

Low voltage = scar/fibrosis

Identifies areas needing additional ablation (e.g., posterior wall scar)

Activation map:

Visualizes wavefront propagation

Essential for diagnosing and ablating macroreentrant atrial flutters and organized atrial tachycardias

8. What is the current role of Afib ablaton outside pulmonary vein isolation?

While Pulmonary Vein Isolation (PVI) remains the cornerstone of atrial fibrillation (AF) ablation, adjunctive strategies are increasingly used for persistent AF, with varying levels of supporting data.

Non-PVI Triggers:

Arrhythmogenic foci found outside the pulmonary veins in 10% to 20% of patients.

Common sites include SVC, LAA, CS, and Crista Terminalis.

Identifying and ablating these inducible triggers—often provoked by isoproterenol—can reduce recurrence in persistent AF.

Posterior Wall Isolation (PWI):

The posterior wall is a driver for persistent AF.

Randomized evidence for routine PWI is conflicting.

Large RCTs found no significant benefit over PVI alone for first-time ablations.

Remains a primary adjunctive target for redo procedures.

AI-Guided Ablation:

Uses AI to identify “spatio-temporal dispersion” areas.

Recent TAILORED-AF trial demonstrate increased freedom from AF at 12 months compared to conventional PVI.

9. Comparison of ablation techniques

Pulsed Field Ablation (PFA) – Non-Thermal

Mechanism: irreversible electroporation

Key advantages:

Shorter procedural time

Comparable efficacy to thermal ablation

Higher myocardial tissue selectivity

No known risk of esophageal fistula or pulmonary vein stenosis

Low risk of phrenic nerve (usually transient)

Disadvantages:

Less flexibility for complex substrate

Hemolysis with possible AKI

Early and delayed coronary spasms

Skeletal muscle stimulation during energy delivery

Loss of all electrograms even with reversible injury can be misleading

Limited long term data

Radiofrequency Ablation (RFA) – Thermal (Heat)

Mechanism: resistive heating

Key advantages:

Highly versatile

Can tailor lesions

Long term experience

Disadvantages:

More procedural time (less with ultrahigh power RFA)

Very small risk of esophageal fistula (1/2000 but 50% mortality!)

Pulmonary vein stenosis

Rare Phrenic nerve palsy

Stem pops

Cryoballoon Ablation (CBA) – Thermal (Cold)

Mechanism: Uses extreme cold

Key Advantages:

Short learning curve

Single shot balloon

Highly reproducible

Good catheter stability (adhesion during freeze)

Low risk of thrombus

Disadvantages:

Similar to RFA

More phrenic nerve palsy

Less esophageal fistula and pulmonary vein stenosis

10. Other Complications of AF Catheter Ablation common to all modalities

Pericardial effusion/tamponade: 0.4–2.2%

Stroke/TIA: ~0.2–1.8%

In-hospital mortality: Very low (0.05–0.46%)

Often overstated in studies based on National Inpatient Sample (NIS) due to selection bias

Vascular access complications: Hematoma

11. Expert approach to Antiarrhythmic Drug (AAD) Therapy After AF Ablation

Continue AAD for the 3-month blanking period after catheter ablation.

Supported by multiple trials to reduce early AF recurrences.

Decreases hospitalizations during the healing phase by suppressing inflammation-related arrhythmias.

AADs do not clearly improve long-term freedom from AF.

At the 3-month follow-up:

If the patient is asymptomatic with no documented recurrence → discontinue AAD.

If recurrent AF occurs or high substrate burden persists → consider continuing AAD.

12. Expert approach to Anticoagulation After AF Ablation

All patients require anticoagulation for at least 3 months post–ablation.

Current guidelines recommend long-term anticoagulation decisions guided solely by CHA₂DS₂-VASc score.

Decisions should not be based on ablation success or arrhythmia burden.

New data support discontinuation in low-risk patients after careful shared decision-making.

In high-risk patients:

Observational data indicate ~2.5-fold increased stroke risk when anticoagulation is stopped.

OCEAN trial:

Generally low risk patients (mean CHA2DS2-VASc score 2.2).

Rivaroxaban did not significantly reduce composite stroke outcomes compared with aspirin.

13. Approach to recurrent Atrial Arrhythmias After AF Ablation

Early (≤3 months – blanking period):

True blanking probably less (6 weeks to 2 months)

Likely less with PFA

Often due to inflammation or lesion maturation

Should not be considered procedural failure

Management:

Continue or restart AAD

Electrical cardioversion for persistent symptomatic episodes

Avoid early repeat ablation

Late (>3 months) recurrences:

More likely due to pulmonary vein reconnection or residual atrial substrate

Arrhythmias include:

Recurrent atrial fibrillation

Atypical (macroreentrant) atrial flutter

Typical atrial flutter (cavotricuspid isthmus–dependent)

Focal atrial tachycardia

Management is often challenging and may include AAD, cardioversion, or repeat ablation.

14. When to Consider Hybrid Surgical and Catheter Ablation for Atrial Fibrillation?

Aggressive rhythm control strategy when standard endocardial approaches are insufficient.

Typically for persistent or long-standing persistent AF (>12 months).

Often used in patients with extensive substrate or multiple failed catheter ablations.

Can be performed during concomitant cardiac surgery or as a stand-alone hybrid procedure.

Benefits of surgical approach:

Epicardial posterior wall/dome ablation

PVI

Ligation of the ligament of Marshall

Left atrial appendage closure (e.g., AtriClip)

Approach:

Subxiphoid/minimally invasive surgical access

Endocardial EP confirmation

Additional PVI ablation and gap closure

Evidence suggests increased freedom from atrial arrhythmias at the expense of higher major adverse event risk.