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Score-Based Versus Clinical Evaluation of Heart Failure Severity among Patients Listed for Heart Transplantation
The 17th Annual Scientific Meeting
HFSA
S21
Molecular Biology and Genetics 056 Right Ventricular Systolic and Diastolic Function as Assessed by SpeckleTracking Echocardiography Improve with Long-Term Left Ventricular Assist Device Support Jerrell W. Herod, Amrut V. Ambardekar; University of Colorado, Aurora, CO Introduction: Right ventricular (RV) failure is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. As a LVAD primarily supports the left ventricle, it is unknown whether RV pathology progresses over time leading to deterioration in RV function among patients chronically supported with a LVAD. RV longitudinal strain and strain rate as measured by speckle-tracking echocardiography provide a more sensitive, reproducible, and quantitative assessment of RV systolic and diastolic function than conventional echocardiography. Since LVADs decrease left sided filling pressure, reduce pulmonary pressure, and reduce RV afterload we hypothesized that RV systolic and diastolic function would remain stable or even improve after prolonged continuous-flow LVAD support. Methods: Echocardiograms were retrospectively reviewed from before and after implantation of a HeartMate II LVAD between 2006 and 2013 at a single center. Patients who had a baseline echocardiogram before LVAD that was performed off inotropes and a follow up echocardiogram after at least 2 months of LVAD support were included in the analysis. Patients were excluded if they required a RV assist device, had a LVAD malfunction, or had poor echocardiographic visualization of the RV endocardium. The speckle-tracking analysis software Velocity Vector Imaging (Siemens Medical) was used to calculate global RV longitudinal systolic strain, strain rate, and diastolic strain rate. Paired t-tests compared measures at baseline before LVAD to the time of maximal follow up after LVAD implantation. Results: Of the 75 LVAD patients screened, 32 had a baseline echocardiogram off inotropes before LVAD along with a paired echocardiogram at least 2 months after LVAD implantation. 15 patients met exclusion criteria, leaving an analysis cohort of 17 patients with a mean duration of LVAD support at the time of the follow up echocardiogram of 2716129 days. Global RV longitudinal strain improved in 12 of 17 patients (70%) with the average RV strain decreasing from -7.962.3% before to -9.863.4% after LVAD (p50.034). Similarly, RV longitudinal systolic strain rate improved in 11 patients (64%) with the average RV systolic strain rate decreasing from -0.6760.24%/sec before to -0.9960.35%/sec after LVAD (p50.002). Finally RV longitudinal diastolic strain rate improved in 14 patients (82%) with the average RV diastolic strain rate increasing from 0.7760.33%/sec before to 0.9960.33%/sec after LVAD (p50.029). Conclusions: Among LVAD patients who did not require a RV assist device, RV systolic and diastolic function as determined by speckle-tracking echocardiography improved in the majority of patients during chronic LVAD support. This suggests that LVADs prevent progression of RV dysfunction in this group of patients and emphasizes the need for strategies for temporary support of the failing RV in the initial period after LVAD implantation to allow for long term stabilization and improvement in RV function.
LVAD respectively. A subset of patients (n522) had pre and post-LVAD HbA1c which improved significantly post-LVAD, 7.90 6 1.17% vs. 6.52 6 1.21%; p59.37 x 10-5. Similarly in a subset of 18 patients with paired C-reactive protein (CRP) levels pre and post-LVAD, CRP decreased from 44.33 6 42.69 mg/L to 22.28 6 24.88 mg/L; p50.059. There were no significant differences in aspartate aminotransferase and alanine aminotransferase levels pre and post-LVAD. Conclusion: Diabetic patients with advanced stages of HF appear to have significant improvement in glycemic control and require less use of treatment medications for diabetes after LVAD implantation. This may be due to improved cardiac output, decreased inflammation, and/or reduced insulin resistance.
058 Score-Based Versus Clinical Evaluation of Heart Failure Severity among Patients Listed for Heart Transplantation Anjan Deka, Song Li, Lampros Papadimitriou, Sarawut Siwamogsatham, Catherine Marti, Divya Gupta, Robert Cole, Andrew L. Smith, Sonjoy Laskar, Andreas Kalogeropoulos, Javed Butler, Vasiliki Georgiopoulou; Emory University, Atlanta, GA Introduction: Identification of patients with heart failure (HF), who will need advanced therapies including heart transplant (HTx), is challenging. Most of the time clinical assessment is used for this purpose, although prediction schemes are available. The association between clinical assessment of HF severity versus a formal risk prediction scheme has not been described. Hypothesis: We hypothesized that the clinical assessment of HF severity performed by physicians is associated with the disease severity calculated using a formal risk prediction scheme. Methods: We retrospectively evaluated 320 adults ($18 years old) listed for HTx from 1997 to 2011. Listing decision was based on cumulative patient data discussion among HTx team members without use of risk prediction scores. HF severity was assigned to patients based on United Network for Organ Sharing listing status 1A, 1B, or 2 and was compared for average score using the Seattle Heart Failure Score (SHFS). Results: Overall 33 patients were listed as status 1A (10.3%), 136 (42.5%) as 1B, and 151 (47.2%) as 2. Age was 51.5611.3 years; 62 (19.4%) were women; 102 (31.9%) black; 209 (65.3%) white; ejection fraction was 15.167.8%; and 137 (42.8%) patients had ischemic HF. Treatment included angiotensin system inhibitors in 248 patients (77.5%), beta-blockers in 252 (78.8%), and aldosterone antagonists in 163 (50.9%), whereas 261 (81.6%) had a biventricular pacemaker and/or defibrillator. The median (interquartile range) SHFS was 1.85 (1.32, 2.04), 1.36 (0.73, 2.04), and 0.64 (0.07, 1.18) in patients listed as status 1A, 1B and 2, respectively, P!0.001 (Figure 1), corresponding to projected 1-year mortality of 25%, 19%, and 10%, respectively (Figure 2). Conclusion: Clinically evaluated HF severity for HTx listing correlates optimally with formal risk score directionally, as well as with clinically meaningful differences in projected prognosis.
057 Improvement in Glycemic Control after Left Ventricular Assist Device Implantation in Advanced Heart Failure Patients with Diabetes Mellitus Naila Choudhary, Leway Chen, Lisa Kotyra, Steven Wittlin, Jeffrey Alexis; University of Rochester Medical Center, Rochester, NY Introduction: Patients with advanced heart failure (HF) often have a co-existing diagnosis of diabetes mellitus. Insulin resistance is an independent risk factor for death in HF patients and is associated with the severity of HF. Left ventricular assist devices (LVAD) have been shown to improve outcomes in advanced stages of HF. In this study we hypothesized that LVAD implantation improves glycemic control in patients with end-stage HF. Methods: A retrospective chart review was done on 202 patients who required mechanical circulatory support (MCS) from November 2006 to December 2012. A total of 63 patients met at least one inclusion criterion of history of diabetes mellitus, treatment with insulin or oral hypoglycemic agents or both, fasting blood glucose (FBG) O 125 mg/dL, and hemoglobin A1c (HbA1c) O 6.5%. 13 patients were excluded due to death during LVAD implant hospitalization, initial diagnosis of diabetes at the time of LVAD implantation, or implant of right ventricular assist device only or extra-corporeal membrane oxygenation only. Laboratory data and data on management of diabetes were collected on 50 patients within 2 months prior to LVAD implantation and at 5.55 6 1.13 months post-LVAD implantation. Results: Of 50 patients who met the inclusion and exclusion criteria, 42 (84%) were male. Mean age at time of implant was 56 6 10.89 years. Etiology of HF was ischemic in 31 (62%) patients and non-ischemic in 19 (38%) patients. There was no significant difference in weight, BMI, hemoglobin, hematocrit and renal function preLVAD and post-LVAD. FBG improved from 136.04 6 34.84 mg/dL to 108.26 6 29.13 mg/dL post-LVAD; p55.96 x 10-7. In 23 patients taking insulin, total daily insulin dose was 53.74 6 51.53 units pre-LVAD and 35.61 6 30.70 units post-LVAD; p50.012. Of the 22 patients taking oral hypoglycemic agents (OHA) pre-LVAD, 11 patients did not require OHA post-LVAD, 3 patients were switched from OHA to insulin post-VAD, 2 patients required higher dose of OHA post-VAD and 6 patients continued the same dose. In 13 patients treated with only glargine as an anti-diabetic agent, FBG and insulin dose were 146.85 6 41.53 mg/dL vs. 117.77 6 35.13 mg/dL (p50.03) and 38.08 6 22.98 units vs. 27.08 6 18.67 units (p50.05) pre and post-
059 Mortality of Patients with Heart Failure and Reduced Ejection Fraction (HFrEF) Who Receive Either ICD or CRT-D Has Improved Yearly from 2003 to 2010: The Altitude Registry JoAnn Lindenfeld1, Brian D. Powell2, David L. Hayes3, Niraj Varma4, Paul Jones5, Nicholas Wold5, Leslie A. Saxon6; 1Univ of Colorado, Aurora, CO; 2Carolina HealthCare, Charlotte, NC; 3Mayo CLinic, Rochester, MN; 4Cleveland Clinic Foundation, Cleveland, CO; 5Boston Scientific, St. Paul, MN; 6University of Southern California, Los Angeles, CA Background: Despite significant advances in medical and device therapy for patients with heart failure(HF) and reduced ejection fraction, HF remains a highly morbid and mortal disease. Estimates of mortality are often based on clinical trials completed several years ago. Event rates for patients receiving ICD and CRT-D are important considerations for planning clinical trials and for accurately predicting mortality for patients. Purpose: To determine the mortality of patients receiving either CRT-D or ICD for either primary or secondary prevention in a large"real world" registry(ALTITUDE) between 2003 and 2010. Methods: Mortality was assessed for patients receiving either primary or secondary prevention ICD (n 5 182,394) or CRT-D(n 5 119,551) devices between January 1,
HFSA
S21
Molecular Biology and Genetics 056 Right Ventricular Systolic and Diastolic Function as Assessed by SpeckleTracking Echocardiography Improve with Long-Term Left Ventricular Assist Device Support Jerrell W. Herod, Amrut V. Ambardekar; University of Colorado, Aurora, CO Introduction: Right ventricular (RV) failure is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. As a LVAD primarily supports the left ventricle, it is unknown whether RV pathology progresses over time leading to deterioration in RV function among patients chronically supported with a LVAD. RV longitudinal strain and strain rate as measured by speckle-tracking echocardiography provide a more sensitive, reproducible, and quantitative assessment of RV systolic and diastolic function than conventional echocardiography. Since LVADs decrease left sided filling pressure, reduce pulmonary pressure, and reduce RV afterload we hypothesized that RV systolic and diastolic function would remain stable or even improve after prolonged continuous-flow LVAD support. Methods: Echocardiograms were retrospectively reviewed from before and after implantation of a HeartMate II LVAD between 2006 and 2013 at a single center. Patients who had a baseline echocardiogram before LVAD that was performed off inotropes and a follow up echocardiogram after at least 2 months of LVAD support were included in the analysis. Patients were excluded if they required a RV assist device, had a LVAD malfunction, or had poor echocardiographic visualization of the RV endocardium. The speckle-tracking analysis software Velocity Vector Imaging (Siemens Medical) was used to calculate global RV longitudinal systolic strain, strain rate, and diastolic strain rate. Paired t-tests compared measures at baseline before LVAD to the time of maximal follow up after LVAD implantation. Results: Of the 75 LVAD patients screened, 32 had a baseline echocardiogram off inotropes before LVAD along with a paired echocardiogram at least 2 months after LVAD implantation. 15 patients met exclusion criteria, leaving an analysis cohort of 17 patients with a mean duration of LVAD support at the time of the follow up echocardiogram of 2716129 days. Global RV longitudinal strain improved in 12 of 17 patients (70%) with the average RV strain decreasing from -7.962.3% before to -9.863.4% after LVAD (p50.034). Similarly, RV longitudinal systolic strain rate improved in 11 patients (64%) with the average RV systolic strain rate decreasing from -0.6760.24%/sec before to -0.9960.35%/sec after LVAD (p50.002). Finally RV longitudinal diastolic strain rate improved in 14 patients (82%) with the average RV diastolic strain rate increasing from 0.7760.33%/sec before to 0.9960.33%/sec after LVAD (p50.029). Conclusions: Among LVAD patients who did not require a RV assist device, RV systolic and diastolic function as determined by speckle-tracking echocardiography improved in the majority of patients during chronic LVAD support. This suggests that LVADs prevent progression of RV dysfunction in this group of patients and emphasizes the need for strategies for temporary support of the failing RV in the initial period after LVAD implantation to allow for long term stabilization and improvement in RV function.
LVAD respectively. A subset of patients (n522) had pre and post-LVAD HbA1c which improved significantly post-LVAD, 7.90 6 1.17% vs. 6.52 6 1.21%; p59.37 x 10-5. Similarly in a subset of 18 patients with paired C-reactive protein (CRP) levels pre and post-LVAD, CRP decreased from 44.33 6 42.69 mg/L to 22.28 6 24.88 mg/L; p50.059. There were no significant differences in aspartate aminotransferase and alanine aminotransferase levels pre and post-LVAD. Conclusion: Diabetic patients with advanced stages of HF appear to have significant improvement in glycemic control and require less use of treatment medications for diabetes after LVAD implantation. This may be due to improved cardiac output, decreased inflammation, and/or reduced insulin resistance.
058 Score-Based Versus Clinical Evaluation of Heart Failure Severity among Patients Listed for Heart Transplantation Anjan Deka, Song Li, Lampros Papadimitriou, Sarawut Siwamogsatham, Catherine Marti, Divya Gupta, Robert Cole, Andrew L. Smith, Sonjoy Laskar, Andreas Kalogeropoulos, Javed Butler, Vasiliki Georgiopoulou; Emory University, Atlanta, GA Introduction: Identification of patients with heart failure (HF), who will need advanced therapies including heart transplant (HTx), is challenging. Most of the time clinical assessment is used for this purpose, although prediction schemes are available. The association between clinical assessment of HF severity versus a formal risk prediction scheme has not been described. Hypothesis: We hypothesized that the clinical assessment of HF severity performed by physicians is associated with the disease severity calculated using a formal risk prediction scheme. Methods: We retrospectively evaluated 320 adults ($18 years old) listed for HTx from 1997 to 2011. Listing decision was based on cumulative patient data discussion among HTx team members without use of risk prediction scores. HF severity was assigned to patients based on United Network for Organ Sharing listing status 1A, 1B, or 2 and was compared for average score using the Seattle Heart Failure Score (SHFS). Results: Overall 33 patients were listed as status 1A (10.3%), 136 (42.5%) as 1B, and 151 (47.2%) as 2. Age was 51.5611.3 years; 62 (19.4%) were women; 102 (31.9%) black; 209 (65.3%) white; ejection fraction was 15.167.8%; and 137 (42.8%) patients had ischemic HF. Treatment included angiotensin system inhibitors in 248 patients (77.5%), beta-blockers in 252 (78.8%), and aldosterone antagonists in 163 (50.9%), whereas 261 (81.6%) had a biventricular pacemaker and/or defibrillator. The median (interquartile range) SHFS was 1.85 (1.32, 2.04), 1.36 (0.73, 2.04), and 0.64 (0.07, 1.18) in patients listed as status 1A, 1B and 2, respectively, P!0.001 (Figure 1), corresponding to projected 1-year mortality of 25%, 19%, and 10%, respectively (Figure 2). Conclusion: Clinically evaluated HF severity for HTx listing correlates optimally with formal risk score directionally, as well as with clinically meaningful differences in projected prognosis.
057 Improvement in Glycemic Control after Left Ventricular Assist Device Implantation in Advanced Heart Failure Patients with Diabetes Mellitus Naila Choudhary, Leway Chen, Lisa Kotyra, Steven Wittlin, Jeffrey Alexis; University of Rochester Medical Center, Rochester, NY Introduction: Patients with advanced heart failure (HF) often have a co-existing diagnosis of diabetes mellitus. Insulin resistance is an independent risk factor for death in HF patients and is associated with the severity of HF. Left ventricular assist devices (LVAD) have been shown to improve outcomes in advanced stages of HF. In this study we hypothesized that LVAD implantation improves glycemic control in patients with end-stage HF. Methods: A retrospective chart review was done on 202 patients who required mechanical circulatory support (MCS) from November 2006 to December 2012. A total of 63 patients met at least one inclusion criterion of history of diabetes mellitus, treatment with insulin or oral hypoglycemic agents or both, fasting blood glucose (FBG) O 125 mg/dL, and hemoglobin A1c (HbA1c) O 6.5%. 13 patients were excluded due to death during LVAD implant hospitalization, initial diagnosis of diabetes at the time of LVAD implantation, or implant of right ventricular assist device only or extra-corporeal membrane oxygenation only. Laboratory data and data on management of diabetes were collected on 50 patients within 2 months prior to LVAD implantation and at 5.55 6 1.13 months post-LVAD implantation. Results: Of 50 patients who met the inclusion and exclusion criteria, 42 (84%) were male. Mean age at time of implant was 56 6 10.89 years. Etiology of HF was ischemic in 31 (62%) patients and non-ischemic in 19 (38%) patients. There was no significant difference in weight, BMI, hemoglobin, hematocrit and renal function preLVAD and post-LVAD. FBG improved from 136.04 6 34.84 mg/dL to 108.26 6 29.13 mg/dL post-LVAD; p55.96 x 10-7. In 23 patients taking insulin, total daily insulin dose was 53.74 6 51.53 units pre-LVAD and 35.61 6 30.70 units post-LVAD; p50.012. Of the 22 patients taking oral hypoglycemic agents (OHA) pre-LVAD, 11 patients did not require OHA post-LVAD, 3 patients were switched from OHA to insulin post-VAD, 2 patients required higher dose of OHA post-VAD and 6 patients continued the same dose. In 13 patients treated with only glargine as an anti-diabetic agent, FBG and insulin dose were 146.85 6 41.53 mg/dL vs. 117.77 6 35.13 mg/dL (p50.03) and 38.08 6 22.98 units vs. 27.08 6 18.67 units (p50.05) pre and post-
059 Mortality of Patients with Heart Failure and Reduced Ejection Fraction (HFrEF) Who Receive Either ICD or CRT-D Has Improved Yearly from 2003 to 2010: The Altitude Registry JoAnn Lindenfeld1, Brian D. Powell2, David L. Hayes3, Niraj Varma4, Paul Jones5, Nicholas Wold5, Leslie A. Saxon6; 1Univ of Colorado, Aurora, CO; 2Carolina HealthCare, Charlotte, NC; 3Mayo CLinic, Rochester, MN; 4Cleveland Clinic Foundation, Cleveland, CO; 5Boston Scientific, St. Paul, MN; 6University of Southern California, Los Angeles, CA Background: Despite significant advances in medical and device therapy for patients with heart failure(HF) and reduced ejection fraction, HF remains a highly morbid and mortal disease. Estimates of mortality are often based on clinical trials completed several years ago. Event rates for patients receiving ICD and CRT-D are important considerations for planning clinical trials and for accurately predicting mortality for patients. Purpose: To determine the mortality of patients receiving either CRT-D or ICD for either primary or secondary prevention in a large"real world" registry(ALTITUDE) between 2003 and 2010. Methods: Mortality was assessed for patients receiving either primary or secondary prevention ICD (n 5 182,394) or CRT-D(n 5 119,551) devices between January 1,