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Preoperative MELD-XI is not Associated with Mortality after LVAD
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Journal of Cardiac Failure Vol. 24 No. 8S August 2018 MELD-XI is not associated with mortality after LVAD implantation. These findings need to be validated in a larger group registry to identify best bridging strategy in patients with advanced heart failure and combined kidney-liver dysfunction.
286 LVAD-DT as the Final Destination: End-of-Life Experiences Lisa Kitko1, Judith Hupcey2, Windy Alonso3, Abigail McGinnis1, Barb Birriel2; 1 Penn State University, University Park, PA; 2Penn State University, Hershey, PA; 3 University of Nebraska Medical Center, Omaha, NE
Figure 1. Minnesota Living with Heart Failure Questionnaire scores in enrollees patients at 0 and 6 Months.
Introduction: As the number of persons living with advanced heart failure (HF) continues to increase, so does the implantation of mechanical circulatory support devices. Over half of the left ventricular assist devices (LVADs) currently implanted are indicated for destination therapy (DT) but there is a gap in the current evidence regarding the end-of-life experiences (EOL) of this group. Purpose: To investigate the EOL experiences of LVAD-DT recipients and their family caregivers throughout the LVAD-DT trajectory including: 1) pre-implantation experiences, 2) conversations about device deactivation, 3) use of EOL services including palliative care and hospice, and 4) device deactivation prior to death. Methods: Thirty five individuals and their family caregivers (n=70) from 2 longitudinal prospective studies participated in qualitative interviews that occurred approximately every month for up to 24 months or until the death of the LVAD-DT recipient. After the death of LVAD-DT recipient, the caregiver was interviewed about LVAD deactivation and use of EOL services. Qualitative content analysis was utilized to explore the experiences of participants through the EOL. EOL service utilization determined via EMR review. Results: During study enrollment LVAD-DT recipients had on average 6 readmissions. The main reasons for readmission included: infection/ sepsis, GI bleed, RHF, and anemia. Sixty percent of the dyads (21/35) received a palliative care consult prior to implantation. Of those only 19% (4/21) recalled the consultation. Six out of thirty five (17%) had an advance directive in the EMR. All advance directives were completed prior to LVAD-DT implantation and none included documentation of wishes for device deactivation. The main results from the content analysis highlighted the lack of EOL planning. LVAD-DT recipients and caregivers did not recall advance care planning or conversations regarding device deactivation throughout the LVAD trajectory. Six patients died with an LVAD in place. Of those, 2 received no EOL services, 3 had EOL services only during their terminal hospitalization, and 1 had ongoing EOL services during the last month of life with deactivation in the home setting prior to death. Conclusions: The pre-implantation period is a very busy time, if palliative care consults occurred they often were not remembered by the LVAD recipient or their family member. EOL services were not routinely initiated nor did they transition across episodes of care or settings, despite frequent hospitalizations in the post-implantation period. Additional research is needed on the role of improved EOL care coordination across settings and episodes of care.
285 Preoperative MELD-XI is not Associated with Mortality after LVAD Mohamed Khayata, Sadeer Al-Kindi, Muhammad S. Panhwar, Linda Njoroge, Salil Deo, Benjamin Medalian, Monique R. Robinson, Mahazarin Ginwalla, Michael Zacharias, Chantal A. ElAmm, Guilherme H. Oliveira; University Hospitals Cleveland Medical Center, Cleveland, OH Background: Kidney and liver dysfunction are common in patients with advanced heart failure undergoing left ventricular assistant device (LVAD) implantation. We have previously shown that Model of End-Stage Liver Disease excluding INR (MELD-XI) scores can predict poor outcomes after heart transplantation. Whether MELD-XI predicts outcomes after LVAD implantation is not well understood. Methods: All patients who underwent LVAD implantation at a tertiary referral center (2007-2017) were included and preoperative MELD-XI was calculated. Cox proportional hazard models and Kaplan Meier method were used to describe association with overall post-implant mortality. Penalized smoothed splines were used to visualize the association between continuous MELDXI and mortality. Results: A total of 94 patients were included. Mean age was 60§13 years, 78% males, 64% Caucasian, 76% had the HeartMate II. Median MELD-XI was 12.4(9.9-15.9). At a median follow-up of 2.8 years, 31 patients died. There was no difference between patients with MELD-XI >12.4 and MELD-XI 12.4 in overall mortality (P=0.14), figure (panel A). There was no association between continuous MELD-XI and mortality (HR 1.04; 95% CI: 0.96-1.13, P=0.32), figure (panel B). Conclusion: Our findings showed that
287 Real-time Application of an Inpatient Heart Failure Mortality Model to Predict 30-Day Mortality Connie M. Lewis1, Zachary L. Cox1,2, Pikki Lai1, JoAnn Lindenfeld1, Sean Collins1; 1 Vanderbilt University Medical Center, Nashville, TN; 2Lipscomb University College of Pharmacy, Nashville, TN Background: A CART model using admission systolic blood pressure (SBP), blood urea nitrogen (BUN), and serum creatinine (SCr) is proven to discern HF in-patient mortality risk. However, this model was not able to evaluate post-discharge outcomes. Objective: We sought to 1) investigate an established HF in-patient mortality CART model’s ability to discern 30-day all-cause mortality risk at an academic medical center and 2) investigate the potential to implement it in a real-time HF dashboard within the EMR Methods: We have previously derived and validated a region-specific risk tool using CMS data on Medicare beneficiaries, age >65 years admitted to Vanderbilt University Medical Center with a primary diagnosis of acute HF from July 2009 to June 2016. We then applied the pre-specified threshold values from the aforementioned CART model for admission SBP, BUN, and SCr to evaluate 30-day all-cause mortality across the 5 resultant risk groups. We explored the presence of the model’s data points at admission, the ability to automatically extract the data, and the ability to present a risk score in a real-time HF dashboard within the EMR. We utilized the CMS mortality report
Journal of Cardiac Failure Vol. 24 No. 8S August 2018 MELD-XI is not associated with mortality after LVAD implantation. These findings need to be validated in a larger group registry to identify best bridging strategy in patients with advanced heart failure and combined kidney-liver dysfunction.
286 LVAD-DT as the Final Destination: End-of-Life Experiences Lisa Kitko1, Judith Hupcey2, Windy Alonso3, Abigail McGinnis1, Barb Birriel2; 1 Penn State University, University Park, PA; 2Penn State University, Hershey, PA; 3 University of Nebraska Medical Center, Omaha, NE
Figure 1. Minnesota Living with Heart Failure Questionnaire scores in enrollees patients at 0 and 6 Months.
Introduction: As the number of persons living with advanced heart failure (HF) continues to increase, so does the implantation of mechanical circulatory support devices. Over half of the left ventricular assist devices (LVADs) currently implanted are indicated for destination therapy (DT) but there is a gap in the current evidence regarding the end-of-life experiences (EOL) of this group. Purpose: To investigate the EOL experiences of LVAD-DT recipients and their family caregivers throughout the LVAD-DT trajectory including: 1) pre-implantation experiences, 2) conversations about device deactivation, 3) use of EOL services including palliative care and hospice, and 4) device deactivation prior to death. Methods: Thirty five individuals and their family caregivers (n=70) from 2 longitudinal prospective studies participated in qualitative interviews that occurred approximately every month for up to 24 months or until the death of the LVAD-DT recipient. After the death of LVAD-DT recipient, the caregiver was interviewed about LVAD deactivation and use of EOL services. Qualitative content analysis was utilized to explore the experiences of participants through the EOL. EOL service utilization determined via EMR review. Results: During study enrollment LVAD-DT recipients had on average 6 readmissions. The main reasons for readmission included: infection/ sepsis, GI bleed, RHF, and anemia. Sixty percent of the dyads (21/35) received a palliative care consult prior to implantation. Of those only 19% (4/21) recalled the consultation. Six out of thirty five (17%) had an advance directive in the EMR. All advance directives were completed prior to LVAD-DT implantation and none included documentation of wishes for device deactivation. The main results from the content analysis highlighted the lack of EOL planning. LVAD-DT recipients and caregivers did not recall advance care planning or conversations regarding device deactivation throughout the LVAD trajectory. Six patients died with an LVAD in place. Of those, 2 received no EOL services, 3 had EOL services only during their terminal hospitalization, and 1 had ongoing EOL services during the last month of life with deactivation in the home setting prior to death. Conclusions: The pre-implantation period is a very busy time, if palliative care consults occurred they often were not remembered by the LVAD recipient or their family member. EOL services were not routinely initiated nor did they transition across episodes of care or settings, despite frequent hospitalizations in the post-implantation period. Additional research is needed on the role of improved EOL care coordination across settings and episodes of care.
285 Preoperative MELD-XI is not Associated with Mortality after LVAD Mohamed Khayata, Sadeer Al-Kindi, Muhammad S. Panhwar, Linda Njoroge, Salil Deo, Benjamin Medalian, Monique R. Robinson, Mahazarin Ginwalla, Michael Zacharias, Chantal A. ElAmm, Guilherme H. Oliveira; University Hospitals Cleveland Medical Center, Cleveland, OH Background: Kidney and liver dysfunction are common in patients with advanced heart failure undergoing left ventricular assistant device (LVAD) implantation. We have previously shown that Model of End-Stage Liver Disease excluding INR (MELD-XI) scores can predict poor outcomes after heart transplantation. Whether MELD-XI predicts outcomes after LVAD implantation is not well understood. Methods: All patients who underwent LVAD implantation at a tertiary referral center (2007-2017) were included and preoperative MELD-XI was calculated. Cox proportional hazard models and Kaplan Meier method were used to describe association with overall post-implant mortality. Penalized smoothed splines were used to visualize the association between continuous MELDXI and mortality. Results: A total of 94 patients were included. Mean age was 60§13 years, 78% males, 64% Caucasian, 76% had the HeartMate II. Median MELD-XI was 12.4(9.9-15.9). At a median follow-up of 2.8 years, 31 patients died. There was no difference between patients with MELD-XI >12.4 and MELD-XI 12.4 in overall mortality (P=0.14), figure (panel A). There was no association between continuous MELD-XI and mortality (HR 1.04; 95% CI: 0.96-1.13, P=0.32), figure (panel B). Conclusion: Our findings showed that
287 Real-time Application of an Inpatient Heart Failure Mortality Model to Predict 30-Day Mortality Connie M. Lewis1, Zachary L. Cox1,2, Pikki Lai1, JoAnn Lindenfeld1, Sean Collins1; 1 Vanderbilt University Medical Center, Nashville, TN; 2Lipscomb University College of Pharmacy, Nashville, TN Background: A CART model using admission systolic blood pressure (SBP), blood urea nitrogen (BUN), and serum creatinine (SCr) is proven to discern HF in-patient mortality risk. However, this model was not able to evaluate post-discharge outcomes. Objective: We sought to 1) investigate an established HF in-patient mortality CART model’s ability to discern 30-day all-cause mortality risk at an academic medical center and 2) investigate the potential to implement it in a real-time HF dashboard within the EMR Methods: We have previously derived and validated a region-specific risk tool using CMS data on Medicare beneficiaries, age >65 years admitted to Vanderbilt University Medical Center with a primary diagnosis of acute HF from July 2009 to June 2016. We then applied the pre-specified threshold values from the aforementioned CART model for admission SBP, BUN, and SCr to evaluate 30-day all-cause mortality across the 5 resultant risk groups. We explored the presence of the model’s data points at admission, the ability to automatically extract the data, and the ability to present a risk score in a real-time HF dashboard within the EMR. We utilized the CMS mortality report