Abstract Continuous ambulatory intravenous inotropes can be successfully used as a bridge to decision or heart transplant in patients with end-stage heart failure. The traditional model at our institute involved the Hospital in the Home (HITH) team, with daily nurse-led visits to the patients’ home, to safely maintain this treatment, which is otherwise largely restricted to the intensive care setting. In response to the COVID-19 pandemic, delivery of healthcare underwent a paradigm shift. Our model was changed to a patient led continuous intravenous inotrope program at home which obviated the need for a daily nurse visit. We describe our process and our early outcomes. Fifteen patients were deemed suitable for the Independent at Home program. All patients needed to complete ambulatory intravenous inotrope education, pass competency testing and have implantable cardioverter-defibrillators inserted prior to discharge. Competencies included proficiency for troubleshooting the inotrope ambulatory delivery pump, monitoring of vital signs and ability to report decompensated heart failure symptoms. Weekly outpatient visits to our heart failure clinic with nursing, medical and pharmacy reviews were scheduled. Emergency action plans were provided to patients. 73.3% of our cohort were male. The average age was 51 years. 46.6% had a diagnosis of dilated cardiomyopathy. 53.3% were listed for heart transplant and were bridge to transplant (BTT) and 46.7% were bridge to decision (BTD) for heart transplant. Over a study period of 35 months, seven (46.7%) patients were weaned off inotropes, three (20.0%) were escalated to durable mechanical circulatory support (one due to decompensated heart failure and two due to persistently elevated pulmonary pressures), four (26.7%) were transplanted and one (6.7%) chose to be palliated. Six patients had one admission, five patients had two admissions. Five readmissions were due to decompensated heart failure, four admissions were planned to optimize pulmonary hypertension following a right heart catheterization, three had peripherally inserted central catheter (PICC) line complications and two had non-cardiac admissions (refer to table 1). The median length of days on the Independent at Home program was 112 days with an interquartile range of 120 days. A comparative group consisting of consecutive patients treated under the previous Hospital in the Home model are presented in table 2; the Independent at Home cohort shows reduced unplanned admissions. The independent at home inotrope program is an effective and safe option to bridge to decision or bridge to cardiac transplantation.HITH vs Independent admission reasonHITH vs Independent admissions

Ventricular assist devices (VAD) are lifesaving therapies that provide a temporary solution for patients awaiting heart transplantation. A VAD improves quality of life and reduces waitlist mortality. Antithrombotic therapy, usually with warfarin and aspirin, is required to reduce the risk of thromboembolic complications. In March 2020, a novel pharmacist and nurse-led warfarin point-of-care (POC) management program (PNLP) for VAD patients was established to reduce the requirement for patients to attend pathology clinics during the COVID pandemic, and provide optimal time in therapeutic range (TTR). This retrospective study evaluated the TTR of patients whose warfarin was dosed by the PNLD program. Patients who had a VAD inserted between March 2020 and December 2021 and were taught to use a POC device at home were included. Patients reported POC INR results to the PNLP, with warfarin dose adjustments performed by the credentialled pharmacist. The INR data were collected for 1 year following VAD insertion. The TTR was calculated using the Roosendaal equation [[1]Rosendaal F, et al. Thromb Haemost. 1993;69(3):236–9.Google Scholar]. Thirty patients were included: 23 males, mean age 51.3 (SD 2.5) years, and median follow-up 32 (IQR 20–43) weeks. All patients successfully conducted POC testing at home (median 41 [IQR 30–52] reported INRs) without requiring pathology service visits for INR measurement. The mean TTR was 73.8% (95% CI 66.9–80.9%), which was greater than published historical comparator groups [[2]Martinez BK, et al. Artificial Organs. 2018;42(7):700–4.Google Scholar], with a mean TTR of 46.6% (95% CI 36.0–57.3%). The implementation of the PNLP reduced the need to attend a pathology service and improved TTR compared with published historical data.

Abstract Background Home inotropic support is an established bridge to cardiac transplantation in patients with advanced heart failure. Milrinone, a phosphodiesterase 3 inhibitor, preferentially vasodilates pulmonary vasculature, thus is often chosen over dobutamine in patients with concomitant pulmonary hypertension. However, there is a paucity of data on the haemodynamic effects of milrinone in the pre-cardiac transplant population. Purpose We sought to examine the haemodynamic effects of milrinone vs. dobutamine out to 3 months in patients with advanced heart failure awaiting cardiac transplantation. Methods Patients in the home inotrope program at a quaternary referral centre from January 2000 to May 2022 were included. Retrospective analysis of echocardiographic and invasive haemodynamic studies via right heart catheterisation were performed at baseline (prior to commencement of inotrope), at 30 days (30D) and 3 months (3m). Results From a total of 119 patients, 57 were on milrinone and 62 on dobutamine. Non-ischaemic cardiomyopathies of various aetiologies accounted for 67%, while ischaemic cardiomyopathies accounted for 33%. Majority of patients were male (79%) with a mean age of 52±13 years. There was a significant increase in LVEF from 21±7% at baseline to 27±14% at 3m in those on dobutamine, p = 0.02. Similar increase in LVEF from 22±8% to 26±13% in the milrinone group did not reach significance, p = 0.43. Comparably, CI increased from 2.0±0.6L/min/m2 at baseline to 2.5±0.9L/min/m2 at 3m in the dobutamine cohort, p = 0.05, and from 2.0±0.7L/min/m2 at baseline to 2.3±0.6L/min/m2 at 3m in the milrinone cohort, p = 0.27. In the dobutamine cohort LVEDD was static from 68±14mm at baseline to 66±21mm at 3m, p = 0.78. LVEDD reduced from 67±11mm to 60± 9mm at 3m in the milrinone group, p = 0.09. Classification of mild right ventricular dysfunction increased from 7% to 18% after 30 days on milrinone, p= 0.2, compared to an increase from 10% to 16% in the dobutamine group, p = 0.47. Mean pulmonary artery pressure (mPAP) reduced from 34±11mmHg to 29±11mmHg at 3m in the milrinone group, p = 0.15. mPAP was static in the dobutamine group from 34±9mmHg at baseline to 34±10mmHg at 3m, p = 0.96. TPG in the milrinone group was 11.9±6.0mmHg to 12.9±6.3mmHg at 30D, with reduction at 3m to 9.6±6.3mmHg, p = 0.26. In the dobutamine group TPG remained static from 10.9±5.7mmHg at baseline to 11.4±5.1mmHg at 30D and 10.9±5.2 at 3m, p = 0.97. Wedge pressure (PCWP) reduced from 22±7mmHg at baseline to 21±7mmHg at 30D to 18±8mmHg at 3m in the milrinone group, p = 0.11. PCWP in the dobutamine group was static at 23±8mmHg at baseline to 24±5mmHg at 30D and 23±6mmHg at 3m, p = 0.92. Conclusion(s) Dobutamine demonstrated a significant increase in LVEF and CI out to 3 months, however milrinone demonstrated a larger improvement in RV function and greater reduction in cardiac and pulmonary pressures as compared to dobutamine. Larger studies are required to confirm these trends.Figure 1

Integrated care models for atrial fibrillation (AF) management reduce all-cause mortality and cardiovascular-related hospitalisations and improve adherence to guideline-directed therapies. Establish a nurse and pharmacist-led rapid access AF (RAAF) clinic to bridge the gap from the Emergency Department (ED) to specialist service. Objectives include: to reduce time to specialist care, to improve adherence to guideline directed anticoagulation, and to enhance patient education. From August 2022–February 2023, patients attending ED with AF were referred to the RAAF clinic for comprehensive assessment. Subsequent follow up was triaged to Arrhythmia or General Cardiology outpatient clinics. Patient satisfaction was sought using a Net Promotor Score (NPS) metric (-100 to 100). Fifty-three patients attended clinic (60% first presentation AF, median CHA2DS2-VA of 1 (IQR 0–2.5)). Six patients (11%) had new AF and concurrent heart failure (HF) and received HF education and guideline-directed HF pharmacotherapy. Rhythm at clinic review was AF in 18%; all of whom proceeded to expedited Direct Current Reversion (DCR). Thirty-four patients had a CHA2DS2-VA≥1, of these 26 (76%) were anticoagulated upon ED discharge and a further eight (24%) commenced anticoagulation in clinic. All patients received education regarding risk factor modification. Time to specialist care was reduced by >80% (to ≈16 days from ≈102 days with standard care). Eighteen patients completed the survey (response rate 33%) with 100% reporting a NPS promotor score of 100. An integrated care model delivered through a nurse and pharmacist-led RAAF clinic enhanced AF management through patient education, optimising guideline-directed anticoagulation and reduced time to specialist care.