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Monitoring Aspirin Levels in Patients with LVAD
S342
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
N. Uriel.2 1Internal Medicine, University of Chicago, Chicago, IL; 2Advanced Heart Failure, University of Chicago, Chicago, IL; 3Cardiac Surgery, University of Chicago, Chicago, IL. Purpose: Physical exam is integral to the management of heart failure patients. However, the accuracy of physical exam in patients supported with left ventricular flow assist devices (LVADs) is unknown. This study aims to assess the accuracy of physical exam compared to right heart catheterization (RHC). Methods: Patients with LVADs undergoing RHC were examined by a randomly selected group on the day of RHC. Study participants were asked to determine the following hemodynamic parameters by physical exam: central venous pressure (CVP) above or below 12 mmHg, pulmonary capillary wedge pressure (PCWP) above or below 18 mmHg, and cardiac index (CI) above or below 2.1 L/min/m2. Survey responses were compared to RHC as gold standard. Results: From 2015-2016, 96 physical exam surveys were completed on 30 LVAD patients with an average of 3.2 surveys per patient. 58% of the surveys were completed by residents, 17% by fellows, 11% by attendings, with the remainder completed by VAD coordinators. Overall responses for CVP, PCWP, and CI were correct 73%, 65%, and 78% of the time respectively. Residents and fellows were more often correct regarding CI while attendings were more often correct with RA and PCWP. In comparison to RHC, CVP by physical exam had a sensitivity of 0.62 and specificity of 0.78. PCWP had a sensitivity of 0.49 and specificity of 0.75. CI had a sensitivity of 0.27 and specificity of 0.88. Conclusion: Physical exam was found to be poorly sensitive but highly specific in patients on LVAD support. The accuracy of exam may also vary by level of training. The current findings emphasize the need for invasive assessment of LVAD patients until further non-invasive testing is developed for this population.
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from frequent bleeding episodes with a well controlled INR we dose adjusted the Aspirin to a lower level and found patients had less bleeding episodes with an acceptable level of platelet inhibition. In addition to the study of 50 patients we used the multiplate analysis and found that patients suffering from episodes of VAD thrombosis had a higher than normal TRAP test result. Conclusion: Further studies into the use of platelet function tests are needed. However, a small study has shown patients given the same dose of Aspirin have a different response. In patients with a high response to Aspirin who have a tendency to bleed a lower dose of Aspirin may be given to achieve the same response. 1( 048) Increased Post-Operative Mortality in Patients Undergoing Coronary Artery Bypass Grafting During Left Ventricular Assist Device Implantation P. Mehta ,1 C. Juricek,2 T. Imamura,3 S. Adatya,3 N. Sarswat,3 G. Kim,3 J. Raikhelkar,3 T. Ota,2 V. Jeevanandam,2 G. Sayer,3 N. Uriel.3 1Internal Medicine Residency Program, Department of Medicine, University of Chicago, Chicago, IL; 2Section of Cardiothoracic Surgery, University of Chicago, Chicago, IL; 3Section of Cardiology, University of Chicago, Chicago, IL. Purpose: Left ventricular assist devices (LVADs) have become a mainstay of therapy for advanced heart failure. Selected patients undergo concomitant coronary artery bypass grafting (CABG) at the time of LVAD implantation. This study aimed to assess the perioperative outcomes of combined LVAD implantation and CABG in ischemic cardiomyopathy. Methods: All ischemic cardiomyopathy patients who underwent concomitant CABG during LVAD implantation between 2010-2016 were enrolled. A comparison group was selected, matched for age, gender, heart failure etiology, and device type. Data was collected from the electronic medical record. Outcomes were compared using Kaplan Meier analysis. Results: 79 patients were enrolled. 28 patients, mean age 68 and 96% male, underwent CABG at the time of LVAD (LVAD/CABG), and 51 patients, mean age 66 and 96% male, had LVAD with no CABG. No differences were detected in the baseline characteristics between the groups. CABG was performed to the LAD in 68% of patients while 32% underwent bypass of the RCA. The SVG was used for grafting 75% of the time. Both groups had similar bypass time (175 ± 51 vs. 155 ± 51; p = 0.62). 1-month survival in the LVAD/CABG group was significantly lower; 71.4% compared to 94.1% (p= 0.005) (Fig 1) with hazard ratio for mortality 5.5 (CI; 1.420.6). In-hospital mortality was double in the LVAD/CABG group (32.1% vs 15.7%, p= 0.09). There was no difference in heart failure readmission or ventricular tachycardia between the groups. Conclusion: Concomitant CABG during LVAD implantation carries significant perioperative morbidity and mortality. Addition of CABG to LVAD surgery should be performed only in selected cases after risk assessment and evaluation of the need for revascularization.
WITHDRAWN
1( 047) Monitoring Aspirin Levels in Patients with LVAD R. Hards , G. Edwards, M. Hedger, A.R. Simon. Transplant and Mechanical Circulatory Support, Harefield Hospital, uxbridge, United Kingdom. Purpose: Aspirin is used for platelet inhibition in patients with an LVAD. Aspirin levels can be monitored but this is not common practice. Worldwide Aspirin dosing in LVAD patients variesis depending on the availble strength of Aspirin. To date few studies have looked at platelet function in patients with Ventricular Assist Device's insitu. Methods: 50 patients on VAD support had Multiplate analysis of platelet function carried out.All patients were precribed 150mg Aspirin once daily. Results: A wide variation in response to Aspirin was seen (2u - 145u).2 Patients (4%) were found to have no response to Aspirin at 150mg both were female and overweight, Both patients responded to a higher dose of 225mg of Aspirin. 2 Patients(4%) were found to have no response to Aspirin but on questioning were found to have not taken Aspirin in the last 7 days. 53% of patients with an Aspirin result of below 10u had problems with frequent episodes of bleeding.In patients who had a high response to Aspirin (less than 10u) who were suffering
1( 049) Blood Pressure Measurement in Patients with a HeartMate 3 J. Fischer , A.L. Meyer, K. Jawad, A. Addas, M. Zoric, S. Lehmann, J. Hahn, F.W. Mohr, J. Garbade. Leizpig Heart Center, Leizpig, Germany.
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
N. Uriel.2 1Internal Medicine, University of Chicago, Chicago, IL; 2Advanced Heart Failure, University of Chicago, Chicago, IL; 3Cardiac Surgery, University of Chicago, Chicago, IL. Purpose: Physical exam is integral to the management of heart failure patients. However, the accuracy of physical exam in patients supported with left ventricular flow assist devices (LVADs) is unknown. This study aims to assess the accuracy of physical exam compared to right heart catheterization (RHC). Methods: Patients with LVADs undergoing RHC were examined by a randomly selected group on the day of RHC. Study participants were asked to determine the following hemodynamic parameters by physical exam: central venous pressure (CVP) above or below 12 mmHg, pulmonary capillary wedge pressure (PCWP) above or below 18 mmHg, and cardiac index (CI) above or below 2.1 L/min/m2. Survey responses were compared to RHC as gold standard. Results: From 2015-2016, 96 physical exam surveys were completed on 30 LVAD patients with an average of 3.2 surveys per patient. 58% of the surveys were completed by residents, 17% by fellows, 11% by attendings, with the remainder completed by VAD coordinators. Overall responses for CVP, PCWP, and CI were correct 73%, 65%, and 78% of the time respectively. Residents and fellows were more often correct regarding CI while attendings were more often correct with RA and PCWP. In comparison to RHC, CVP by physical exam had a sensitivity of 0.62 and specificity of 0.78. PCWP had a sensitivity of 0.49 and specificity of 0.75. CI had a sensitivity of 0.27 and specificity of 0.88. Conclusion: Physical exam was found to be poorly sensitive but highly specific in patients on LVAD support. The accuracy of exam may also vary by level of training. The current findings emphasize the need for invasive assessment of LVAD patients until further non-invasive testing is developed for this population.
1( 046)
from frequent bleeding episodes with a well controlled INR we dose adjusted the Aspirin to a lower level and found patients had less bleeding episodes with an acceptable level of platelet inhibition. In addition to the study of 50 patients we used the multiplate analysis and found that patients suffering from episodes of VAD thrombosis had a higher than normal TRAP test result. Conclusion: Further studies into the use of platelet function tests are needed. However, a small study has shown patients given the same dose of Aspirin have a different response. In patients with a high response to Aspirin who have a tendency to bleed a lower dose of Aspirin may be given to achieve the same response. 1( 048) Increased Post-Operative Mortality in Patients Undergoing Coronary Artery Bypass Grafting During Left Ventricular Assist Device Implantation P. Mehta ,1 C. Juricek,2 T. Imamura,3 S. Adatya,3 N. Sarswat,3 G. Kim,3 J. Raikhelkar,3 T. Ota,2 V. Jeevanandam,2 G. Sayer,3 N. Uriel.3 1Internal Medicine Residency Program, Department of Medicine, University of Chicago, Chicago, IL; 2Section of Cardiothoracic Surgery, University of Chicago, Chicago, IL; 3Section of Cardiology, University of Chicago, Chicago, IL. Purpose: Left ventricular assist devices (LVADs) have become a mainstay of therapy for advanced heart failure. Selected patients undergo concomitant coronary artery bypass grafting (CABG) at the time of LVAD implantation. This study aimed to assess the perioperative outcomes of combined LVAD implantation and CABG in ischemic cardiomyopathy. Methods: All ischemic cardiomyopathy patients who underwent concomitant CABG during LVAD implantation between 2010-2016 were enrolled. A comparison group was selected, matched for age, gender, heart failure etiology, and device type. Data was collected from the electronic medical record. Outcomes were compared using Kaplan Meier analysis. Results: 79 patients were enrolled. 28 patients, mean age 68 and 96% male, underwent CABG at the time of LVAD (LVAD/CABG), and 51 patients, mean age 66 and 96% male, had LVAD with no CABG. No differences were detected in the baseline characteristics between the groups. CABG was performed to the LAD in 68% of patients while 32% underwent bypass of the RCA. The SVG was used for grafting 75% of the time. Both groups had similar bypass time (175 ± 51 vs. 155 ± 51; p = 0.62). 1-month survival in the LVAD/CABG group was significantly lower; 71.4% compared to 94.1% (p= 0.005) (Fig 1) with hazard ratio for mortality 5.5 (CI; 1.420.6). In-hospital mortality was double in the LVAD/CABG group (32.1% vs 15.7%, p= 0.09). There was no difference in heart failure readmission or ventricular tachycardia between the groups. Conclusion: Concomitant CABG during LVAD implantation carries significant perioperative morbidity and mortality. Addition of CABG to LVAD surgery should be performed only in selected cases after risk assessment and evaluation of the need for revascularization.
WITHDRAWN
1( 047) Monitoring Aspirin Levels in Patients with LVAD R. Hards , G. Edwards, M. Hedger, A.R. Simon. Transplant and Mechanical Circulatory Support, Harefield Hospital, uxbridge, United Kingdom. Purpose: Aspirin is used for platelet inhibition in patients with an LVAD. Aspirin levels can be monitored but this is not common practice. Worldwide Aspirin dosing in LVAD patients variesis depending on the availble strength of Aspirin. To date few studies have looked at platelet function in patients with Ventricular Assist Device's insitu. Methods: 50 patients on VAD support had Multiplate analysis of platelet function carried out.All patients were precribed 150mg Aspirin once daily. Results: A wide variation in response to Aspirin was seen (2u - 145u).2 Patients (4%) were found to have no response to Aspirin at 150mg both were female and overweight, Both patients responded to a higher dose of 225mg of Aspirin. 2 Patients(4%) were found to have no response to Aspirin but on questioning were found to have not taken Aspirin in the last 7 days. 53% of patients with an Aspirin result of below 10u had problems with frequent episodes of bleeding.In patients who had a high response to Aspirin (less than 10u) who were suffering
1( 049) Blood Pressure Measurement in Patients with a HeartMate 3 J. Fischer , A.L. Meyer, K. Jawad, A. Addas, M. Zoric, S. Lehmann, J. Hahn, F.W. Mohr, J. Garbade. Leizpig Heart Center, Leizpig, Germany.