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Low Cardiac Power Index (CPI) Is Associated With Higher Mortality in Cardiogenic Shock: Stratifying INTERMACS 1 and 2 Patients Undergoing Continuous-Flow LVAD (CF-LVAD) Implantation
Abstracts S57 1( 30)
Low Cardiac Power Index (CPI) Is Associated With Higher Mortality in Cardiogenic Shock: Stratifying INTERMACS 1 and 2 Patients Undergoing Continuous-Flow LVAD (CF-LVAD) Implantation F. Kamdar , N. Sathnur, A. Klaassen Kamdar, P.M. Eckman, R. John. University of Minnesota, Minneapolis, MN. Purpose: Cardiac power output has been demonstrated to be an important hemodynamic predictor of mortality in patients with cardiogenic shock. INTERMACS 1 and 2 profiles reflect cardiogenic shock or impending cardiogenic shock, but these profiles are sometimes subjective. The purpose of this study was to evaluate the prognostic role of CPI in INTERMACS 1 and 2 patients undergoing CF-LVAD. Methods: All patients who underwent CF-LVAD implantation at our institution between 6/2005-7/2014 with INTERMACS profiles 1 and 2 with preLVAD hemodynamics by right heart catheterization were included. Cardiac power index (W/m2) was calculated as MAP (mmHg) × CO (L/min)/ BSA (m2)* 0.0022. Group 1 represented patients with CPI ≤ 0.34 W/m2 and group 2 represented patients with CPI > 0.35 W/m2. Results: 335 patients underwent CF-LVAD implantation, of which 84 patients met the inclusion criteria. There were 49 (58.3%) patients in Group 1 and 35 (41.7%) in Group 2. The average CPI in group 1 was 0.25 W/m2 vs 0.46 W/m2 in group 2 (p = 0.004). There were no significant differences with respect to age, ischemic etiology, duration of LVAD support, ischemic etiology or BTT implant strategy in group 1 vs group 2. Patients in group 1 were more likely to be female (28.5% vs 8.5%, p = 0.03). There were no significant differences in baseline RA pressure, mean PA pressure, or PCWP (p = NS). Group 1 patients had significantly lower SBP, DPB, MAP, CO and CI in comparison to group 2 patients. Survival at 90 days by Kaplan-Meier estimate was significantly lower in group 1 at 73% vs 89% in group 2 (log rank p = 0.049). Lower CPI had a 2.5 times higher odds of mortality at 90 days than those patients with higher CPI. Conclusion: Patients with low CPI who underwent CF- LVAD implantation had increased mortality in comparison to patients with normal CPI. CPI may be a useful and more objective hemodynamic measure to further risk stratify patients with cardiogenic shock who are being considered for CF-LVAD implantation. 1( 31) Concurrent Valvular Procedures During HMII Insertion Are Not Associated With Short or Long-Term Decreased Survival R.M. Adamson ,1 W.P. Dembitsky,1 K.K. Limmer,1 H. Mehta,2 P. Hoagland,2 B. Jaski.2 1Cardiac Surgery, Sharp Memorial Hospital, San Diego, CA; 2Cardiology, Sharp Memorial Hospital, San Diego, CA. Purpose: HeartMate II (HMII) LVADs are frequently placed in patients with concurrent valvular heart disease. Recently published multicenter registry data demonstrated survival disadvantage associated with repairing native valve regurgitation. The question remains whether multicenter registry data or center specific results better predict best practice. Methods: All 211 HMII implants (2005-20013) from a single center were retrospectively analyzed. All patients with concurrent aortic, mitral and/or tricuspid procedures during HMII implantation were compared to patients with isolated HMII placement. Results: The majority of LVAD patients in this series underwent associative native cardiac repair, 79% (160/211) with overall 60% (127/211) having concurrent valvular procedures which included; mitral repair 46% (97/211), tricuspid repair or replacement 21% (45/211), or aortic closure 18% (41/211). A single valvular procedure was performed in 64% (81/127) while 33% (42/127) had 2 procedures and 3% (4/127) had all 3 valves closed, repaired or replaced. Mean age was not different between groups (concurrent valve procedure 65.2 years versus 66.4 years for isolated HMII implants). Operative mortality and 2 year survival were similar to patients not undergoing associated valvular procedures (Figure 1). Survival was not impacted by which valve or number of valves effected. Cardiopulmonary bypass (CPB) averaged 34.9 minutes for patients with isolated HMII placement versus 80.5 minutes for concurrent valvular patients (P< 0.05).
Conclusion: Patients requiring LVAD insertion typically have associated cardiac defects which are often regurgitant valvular lesions. Repairing, replacing or closing insufficient valves is associated with a longer CBP time but does not result in increased operative mortality or decreased survival at 2 years as observed in registry data. Patient informed consent should be based upon treatment center’s specific results and not multicenter registry data. 1( 32) Does Indication for Destination Therapy Affect Left Ventricular Assist Device Outcomes? D. Abramov ,1 N.A. Haglund,1 M.E. Davis,2 Y. Song,3 K. Aaronson,4 F.D. Pagani,5 S. Dunlay,6 J. Stulak,7 S. Maltais.2 1Cardiovascular Medicine, Vanderbilt Univ Med Ctr, Nashville, TN; 2Cardiac Surgery, Vanderbilt Univ Med Ctr, Nashville, TN; 3Biostatistics, Vanderbilt Univ Med Ctr, Nashville, TN; 4Cardiovascular Medicine, University of Michigan, Ann Arbor, MI; 5Cardiac Surgery, University of Michigan, Ann Arbor, MI; 6Cardiovascular Medicine, Mayo Clinic, Rochester, MN; 7Cardiac Surgery, Mayo Clinic, Rochester, MN. Purpose: Destination therapy (DT) indication for left ventricular assist device (LVAD) implantation is increasingly common. Specific reasons for DT indication such as age, obesity and extra-cardiac comorbidities and the effect on LVAD outcomes are unknown. We aim to assess whether the reason for DT indication affects LVAD recipient morbidity and mortality. Methods: We retrospectively assessed 169 patients who were implanted with a HeartMate-II LVAD for DT indication at three institutions from 2007-2014. DT indications were separated into 3 groups: advanced age (> 70), elevated BMI (> 35) and extra-cardiac comorbidities such as diabetic complications were termed ‘other.’ Bridge to decision patients were excluded to maximize DT indication homogeneity. Outcome analyses were performed for survival, gastrointestinal (GI) bleed and thromboembolic events (stroke and pump thrombus). Results: Baseline (male 91%, ischemic 61%, INTERMACS 2.92±1.04) and index LVAD implantation characteristics (bypass time 98±35 min, hospital length of stay 24 ±17 days) were comparable between groups (p> 0.05). Mean follow-up time was 596±547 days. Sixty-eight (40%) patients underwent DT LVAD implant due to advanced age, 40 (24%), elevated BMI and 61 (36%) due to extra-cardiac comorbidities. Event rates per year were comparable between DT groups for ‘any event’ p= 0 .44, GI bleed p= 0 .21, thromboembolic event p= 0 .07, and death p= 0 .10. Overall survival at 1 year was 74% and similar among DT groups (p> 0.05; Figure). Conclusion: Patients undergoing LVAD implantation for DT indications due to advanced age, elevated BMI or extra-cardiac co-morbidities have comparable rates of survival and device complications. These findings have important implications for improving LVAD patient selection and optimizing resource utilization.
Low Cardiac Power Index (CPI) Is Associated With Higher Mortality in Cardiogenic Shock: Stratifying INTERMACS 1 and 2 Patients Undergoing Continuous-Flow LVAD (CF-LVAD) Implantation F. Kamdar , N. Sathnur, A. Klaassen Kamdar, P.M. Eckman, R. John. University of Minnesota, Minneapolis, MN. Purpose: Cardiac power output has been demonstrated to be an important hemodynamic predictor of mortality in patients with cardiogenic shock. INTERMACS 1 and 2 profiles reflect cardiogenic shock or impending cardiogenic shock, but these profiles are sometimes subjective. The purpose of this study was to evaluate the prognostic role of CPI in INTERMACS 1 and 2 patients undergoing CF-LVAD. Methods: All patients who underwent CF-LVAD implantation at our institution between 6/2005-7/2014 with INTERMACS profiles 1 and 2 with preLVAD hemodynamics by right heart catheterization were included. Cardiac power index (W/m2) was calculated as MAP (mmHg) × CO (L/min)/ BSA (m2)* 0.0022. Group 1 represented patients with CPI ≤ 0.34 W/m2 and group 2 represented patients with CPI > 0.35 W/m2. Results: 335 patients underwent CF-LVAD implantation, of which 84 patients met the inclusion criteria. There were 49 (58.3%) patients in Group 1 and 35 (41.7%) in Group 2. The average CPI in group 1 was 0.25 W/m2 vs 0.46 W/m2 in group 2 (p = 0.004). There were no significant differences with respect to age, ischemic etiology, duration of LVAD support, ischemic etiology or BTT implant strategy in group 1 vs group 2. Patients in group 1 were more likely to be female (28.5% vs 8.5%, p = 0.03). There were no significant differences in baseline RA pressure, mean PA pressure, or PCWP (p = NS). Group 1 patients had significantly lower SBP, DPB, MAP, CO and CI in comparison to group 2 patients. Survival at 90 days by Kaplan-Meier estimate was significantly lower in group 1 at 73% vs 89% in group 2 (log rank p = 0.049). Lower CPI had a 2.5 times higher odds of mortality at 90 days than those patients with higher CPI. Conclusion: Patients with low CPI who underwent CF- LVAD implantation had increased mortality in comparison to patients with normal CPI. CPI may be a useful and more objective hemodynamic measure to further risk stratify patients with cardiogenic shock who are being considered for CF-LVAD implantation. 1( 31) Concurrent Valvular Procedures During HMII Insertion Are Not Associated With Short or Long-Term Decreased Survival R.M. Adamson ,1 W.P. Dembitsky,1 K.K. Limmer,1 H. Mehta,2 P. Hoagland,2 B. Jaski.2 1Cardiac Surgery, Sharp Memorial Hospital, San Diego, CA; 2Cardiology, Sharp Memorial Hospital, San Diego, CA. Purpose: HeartMate II (HMII) LVADs are frequently placed in patients with concurrent valvular heart disease. Recently published multicenter registry data demonstrated survival disadvantage associated with repairing native valve regurgitation. The question remains whether multicenter registry data or center specific results better predict best practice. Methods: All 211 HMII implants (2005-20013) from a single center were retrospectively analyzed. All patients with concurrent aortic, mitral and/or tricuspid procedures during HMII implantation were compared to patients with isolated HMII placement. Results: The majority of LVAD patients in this series underwent associative native cardiac repair, 79% (160/211) with overall 60% (127/211) having concurrent valvular procedures which included; mitral repair 46% (97/211), tricuspid repair or replacement 21% (45/211), or aortic closure 18% (41/211). A single valvular procedure was performed in 64% (81/127) while 33% (42/127) had 2 procedures and 3% (4/127) had all 3 valves closed, repaired or replaced. Mean age was not different between groups (concurrent valve procedure 65.2 years versus 66.4 years for isolated HMII implants). Operative mortality and 2 year survival were similar to patients not undergoing associated valvular procedures (Figure 1). Survival was not impacted by which valve or number of valves effected. Cardiopulmonary bypass (CPB) averaged 34.9 minutes for patients with isolated HMII placement versus 80.5 minutes for concurrent valvular patients (P< 0.05).
Conclusion: Patients requiring LVAD insertion typically have associated cardiac defects which are often regurgitant valvular lesions. Repairing, replacing or closing insufficient valves is associated with a longer CBP time but does not result in increased operative mortality or decreased survival at 2 years as observed in registry data. Patient informed consent should be based upon treatment center’s specific results and not multicenter registry data. 1( 32) Does Indication for Destination Therapy Affect Left Ventricular Assist Device Outcomes? D. Abramov ,1 N.A. Haglund,1 M.E. Davis,2 Y. Song,3 K. Aaronson,4 F.D. Pagani,5 S. Dunlay,6 J. Stulak,7 S. Maltais.2 1Cardiovascular Medicine, Vanderbilt Univ Med Ctr, Nashville, TN; 2Cardiac Surgery, Vanderbilt Univ Med Ctr, Nashville, TN; 3Biostatistics, Vanderbilt Univ Med Ctr, Nashville, TN; 4Cardiovascular Medicine, University of Michigan, Ann Arbor, MI; 5Cardiac Surgery, University of Michigan, Ann Arbor, MI; 6Cardiovascular Medicine, Mayo Clinic, Rochester, MN; 7Cardiac Surgery, Mayo Clinic, Rochester, MN. Purpose: Destination therapy (DT) indication for left ventricular assist device (LVAD) implantation is increasingly common. Specific reasons for DT indication such as age, obesity and extra-cardiac comorbidities and the effect on LVAD outcomes are unknown. We aim to assess whether the reason for DT indication affects LVAD recipient morbidity and mortality. Methods: We retrospectively assessed 169 patients who were implanted with a HeartMate-II LVAD for DT indication at three institutions from 2007-2014. DT indications were separated into 3 groups: advanced age (> 70), elevated BMI (> 35) and extra-cardiac comorbidities such as diabetic complications were termed ‘other.’ Bridge to decision patients were excluded to maximize DT indication homogeneity. Outcome analyses were performed for survival, gastrointestinal (GI) bleed and thromboembolic events (stroke and pump thrombus). Results: Baseline (male 91%, ischemic 61%, INTERMACS 2.92±1.04) and index LVAD implantation characteristics (bypass time 98±35 min, hospital length of stay 24 ±17 days) were comparable between groups (p> 0.05). Mean follow-up time was 596±547 days. Sixty-eight (40%) patients underwent DT LVAD implant due to advanced age, 40 (24%), elevated BMI and 61 (36%) due to extra-cardiac comorbidities. Event rates per year were comparable between DT groups for ‘any event’ p= 0 .44, GI bleed p= 0 .21, thromboembolic event p= 0 .07, and death p= 0 .10. Overall survival at 1 year was 74% and similar among DT groups (p> 0.05; Figure). Conclusion: Patients undergoing LVAD implantation for DT indications due to advanced age, elevated BMI or extra-cardiac co-morbidities have comparable rates of survival and device complications. These findings have important implications for improving LVAD patient selection and optimizing resource utilization.