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Treating the Performing Artist
S354
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
Purpose: Right ventricular dysfunction (RVD) and mitral regurgitation (MR) are associated with poor outcomes after left ventricular assist device (LVAD) implantation, and residual MR post-implantation may be associated with poor RV outcomes. We sought to assess predictors of change in MR in patients implanted with continuous flow (CF) LVADs. Methods: 286 patients implanted with CF-LVADs between Jan 2011 - Dec 2015 were analyzed. Demographic, laboratory, clinical and hemodynamic data were obtained from electronic records. Echocardiograms within 3months prior to and within 3-months after surgery were reviewed. A total of 35 potential predictors of change in MR severity pre and post LVAD underwent initial univariable analysis. Variables with p<0.10 were included in the multivariable analysis. Results: Mean age was 57 (§ 12) years, 84% were male, bean LVEF was 17 (§ 6.4) %, and indexed left ventricular end diastolic volume (LVEDVi) was 130 (§ 61) ml/m2. For changes in MR post-op, age, LVEDVi, indexed left atrial volume, degree of pre-op MR, diabetes mellitus, CKD, INTERMACS level, cardiac output, cardiac index, RV stroke work index, sphericity index, average mitral annular diameter, tenting area and coaptation length were identified. On multivariable analysis, LVEDVi and degree of pre-op MR were significant predictors (p = 0.010 and <0.001). Conclusion: For changes in degree of MR, higher pre-operative LVEDVi was associated with worse MR post-surgery, and more severe pre-op MR was associated with improvement in degree of MR post-operatively. These findings suggest pre-implant echocardiographtic assessment of LV size and MR severity can identify patients at increased risk of post-LVAD significant MR. Further analysis is needed to verify the findings of this exploratory study and to determine the effect on clinical outcomes.
associated mortality. One group died of bleeding and repeated infections with a longer survival while the second group died very early following renal and respiratory complications.
890 Delineating Pathways to Death by Multisystem Organ Failure in Patients with a Left Ventricular Assist Device (LVAD) L. Seese,1 F. Movahedi,2 J. Antaki,3 R. Padman,4 S. Murali,5 Y. Zhang,6 A. Kilic,1 C. Sciortino,1 M. Keebler,1 and R. Kormos.1 1Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA; 2Department of Electrical and Computer Engineering, University of Pittsburgh, Pittsburgh, PA; 3Meinig School of Biomedical Engineering, Cornell University, New York, NY; 4The H. John Heinz III College of Information Systems and Public Policy, Carnegie Mellon University, Pittsburgh, PA; 5Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA; and the 6Weill Cornell Medical, Cornell University, New York, NY. Purpose: Multisystem organ failure (MOF) is the second leading cause of death in patients undergoing LVAD therapy. In actuality, MOF is a composite of adverse events (AEs) rather than a singular diagnosis. The objective of this study is to identify the key AEs preceding mortality attributed to MOF. Methods: We analyzed 3,765 AE’s in 554 patients (2006-to-2015) with a continuous flow LVAD whose death was reported due to MOF in the INTERMACS database. For each patient (pt), all AEs that preceded the endpoint death were identified and chronologically ordered into sequences. Hierarchical clustering, a machine learning algorithm for clustering, was used to create a descriptive model of the proportions of each adverse event sequence antecedent to MOF (Figure 1). Results: Two major groups of adverse event sequences were identified: Group 1 (118 pts, 1,461 AEs) and Group 2 (436 pts, 2,304 AEs). Group 1 (Grp1) was temporally distinguished from Group 2 (Grp2) by having a longer median time to death (10 months vs 2 months) and a greater median number of AEs per pt (11/ pt vs 5/pt). In both groups, the most common AEs preceding death were renal and respiratory failure (86% Grp1 and 75% Grp2). Unlike Grp2, Grp1 had more prolonged sequences of recurrent bleeding (66% of pts) originating mainly from the GI tract (51%). Grp 1 also had recurrent infections in 65% of pts that were categorized as bacterial pneumonia in 32%. Furthermore, the predominant sequence in Grp1 that led to MOF was bleeding-to-infection-to-death in 83% of the pt’s AE sequences, whereas MOF most commonly (62%) followed renal failure or respiratory failure, in Grp2. Conclusion: This study used a state of the art machine learning approach to identify two predominant types and sequences of AEs that incite MOF
891 External Assessment of EUROMACS Right-Sided Heart Failure Risk Score H. Shah,1 T. Murray,2 A. El Rafei,3 J. Schultz,1 T. Thenappan,1 T. Alexy,1 R. John,4 C. Martin,1 M. Pritzker,1 and R. Cogswell.1 1Cardiology, University of Minnesota, Minneapolis, MN; 2 Biostatistics, University of Minnesota, Minneapolis, MN; 3Internal Medicine, University of Minnesota, Minneapolis, MN; and the 4 Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN. Purpose: The EUROMACS Right-Sided Heart Failure Risk Score was developed to predict right ventricular failure (RVF) after left ventricular assist device (LVAD) placement. The performance of this model outside the derivation cohort has not been tested. Methods: EUROMACS Right-Sided Heart Failure Risk Scores were calculated and assessed as predictors of post-operative RVF in a single center continuous flow (CF) LVAD cohort (n=451). Only patients with complete data for risk score calculation and RVF determination were included in the analysis (n = 254). RVF was defined as RVAD within 30 days, continuous inotropic support ≥ 14 days, or inhaled pulmonary vasodilatory use for > 48 hours after LVAD implantation. Results: Thirty-nine percent of patients (100/254) had post-operative RVF, however only 9% (23/254) required prolonged inotropic support and 5% (12/254) required RVAD placement. Development of RVF after LVAD was associated with a 45% increase the hazards rate of death on LVAD support (HR 1.45, 95 % CI 0.98-2.2, p =0.066), however this was not statistically significant. The increase in mortality associated with RVF was largely driven by patients who required RVAD support (HR 4.6, 95 % CI 2.3- 9.1, p <0.001). Two of the predictors included in the EUROMACS Right Sided Heart Failure Risk Score were not predictive of RVF in this dataset (hemoglobin, p=0.3, right atrial pressure to pulmonary capillary wedge pressure ratio, p=0.4). The area under the curve for EUROMACS Right-Sided Heart Failure Risk Score to predict RVF was 58% (95 % CI 52-66%). Conclusion: The EUROMACS Right-Sided Heart Failure Risk Score had poor discrimination in this LVAD dataset. These findings further emphasize the difficulty of predicting RVF after LVAD placement. Further work is required to enhance our understanding pre- LVAD right ventricular physiology and to accurately risk stratify patients.
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
Purpose: Right ventricular dysfunction (RVD) and mitral regurgitation (MR) are associated with poor outcomes after left ventricular assist device (LVAD) implantation, and residual MR post-implantation may be associated with poor RV outcomes. We sought to assess predictors of change in MR in patients implanted with continuous flow (CF) LVADs. Methods: 286 patients implanted with CF-LVADs between Jan 2011 - Dec 2015 were analyzed. Demographic, laboratory, clinical and hemodynamic data were obtained from electronic records. Echocardiograms within 3months prior to and within 3-months after surgery were reviewed. A total of 35 potential predictors of change in MR severity pre and post LVAD underwent initial univariable analysis. Variables with p<0.10 were included in the multivariable analysis. Results: Mean age was 57 (§ 12) years, 84% were male, bean LVEF was 17 (§ 6.4) %, and indexed left ventricular end diastolic volume (LVEDVi) was 130 (§ 61) ml/m2. For changes in MR post-op, age, LVEDVi, indexed left atrial volume, degree of pre-op MR, diabetes mellitus, CKD, INTERMACS level, cardiac output, cardiac index, RV stroke work index, sphericity index, average mitral annular diameter, tenting area and coaptation length were identified. On multivariable analysis, LVEDVi and degree of pre-op MR were significant predictors (p = 0.010 and <0.001). Conclusion: For changes in degree of MR, higher pre-operative LVEDVi was associated with worse MR post-surgery, and more severe pre-op MR was associated with improvement in degree of MR post-operatively. These findings suggest pre-implant echocardiographtic assessment of LV size and MR severity can identify patients at increased risk of post-LVAD significant MR. Further analysis is needed to verify the findings of this exploratory study and to determine the effect on clinical outcomes.
associated mortality. One group died of bleeding and repeated infections with a longer survival while the second group died very early following renal and respiratory complications.
890 Delineating Pathways to Death by Multisystem Organ Failure in Patients with a Left Ventricular Assist Device (LVAD) L. Seese,1 F. Movahedi,2 J. Antaki,3 R. Padman,4 S. Murali,5 Y. Zhang,6 A. Kilic,1 C. Sciortino,1 M. Keebler,1 and R. Kormos.1 1Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA; 2Department of Electrical and Computer Engineering, University of Pittsburgh, Pittsburgh, PA; 3Meinig School of Biomedical Engineering, Cornell University, New York, NY; 4The H. John Heinz III College of Information Systems and Public Policy, Carnegie Mellon University, Pittsburgh, PA; 5Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA; and the 6Weill Cornell Medical, Cornell University, New York, NY. Purpose: Multisystem organ failure (MOF) is the second leading cause of death in patients undergoing LVAD therapy. In actuality, MOF is a composite of adverse events (AEs) rather than a singular diagnosis. The objective of this study is to identify the key AEs preceding mortality attributed to MOF. Methods: We analyzed 3,765 AE’s in 554 patients (2006-to-2015) with a continuous flow LVAD whose death was reported due to MOF in the INTERMACS database. For each patient (pt), all AEs that preceded the endpoint death were identified and chronologically ordered into sequences. Hierarchical clustering, a machine learning algorithm for clustering, was used to create a descriptive model of the proportions of each adverse event sequence antecedent to MOF (Figure 1). Results: Two major groups of adverse event sequences were identified: Group 1 (118 pts, 1,461 AEs) and Group 2 (436 pts, 2,304 AEs). Group 1 (Grp1) was temporally distinguished from Group 2 (Grp2) by having a longer median time to death (10 months vs 2 months) and a greater median number of AEs per pt (11/ pt vs 5/pt). In both groups, the most common AEs preceding death were renal and respiratory failure (86% Grp1 and 75% Grp2). Unlike Grp2, Grp1 had more prolonged sequences of recurrent bleeding (66% of pts) originating mainly from the GI tract (51%). Grp 1 also had recurrent infections in 65% of pts that were categorized as bacterial pneumonia in 32%. Furthermore, the predominant sequence in Grp1 that led to MOF was bleeding-to-infection-to-death in 83% of the pt’s AE sequences, whereas MOF most commonly (62%) followed renal failure or respiratory failure, in Grp2. Conclusion: This study used a state of the art machine learning approach to identify two predominant types and sequences of AEs that incite MOF
891 External Assessment of EUROMACS Right-Sided Heart Failure Risk Score H. Shah,1 T. Murray,2 A. El Rafei,3 J. Schultz,1 T. Thenappan,1 T. Alexy,1 R. John,4 C. Martin,1 M. Pritzker,1 and R. Cogswell.1 1Cardiology, University of Minnesota, Minneapolis, MN; 2 Biostatistics, University of Minnesota, Minneapolis, MN; 3Internal Medicine, University of Minnesota, Minneapolis, MN; and the 4 Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN. Purpose: The EUROMACS Right-Sided Heart Failure Risk Score was developed to predict right ventricular failure (RVF) after left ventricular assist device (LVAD) placement. The performance of this model outside the derivation cohort has not been tested. Methods: EUROMACS Right-Sided Heart Failure Risk Scores were calculated and assessed as predictors of post-operative RVF in a single center continuous flow (CF) LVAD cohort (n=451). Only patients with complete data for risk score calculation and RVF determination were included in the analysis (n = 254). RVF was defined as RVAD within 30 days, continuous inotropic support ≥ 14 days, or inhaled pulmonary vasodilatory use for > 48 hours after LVAD implantation. Results: Thirty-nine percent of patients (100/254) had post-operative RVF, however only 9% (23/254) required prolonged inotropic support and 5% (12/254) required RVAD placement. Development of RVF after LVAD was associated with a 45% increase the hazards rate of death on LVAD support (HR 1.45, 95 % CI 0.98-2.2, p =0.066), however this was not statistically significant. The increase in mortality associated with RVF was largely driven by patients who required RVAD support (HR 4.6, 95 % CI 2.3- 9.1, p <0.001). Two of the predictors included in the EUROMACS Right Sided Heart Failure Risk Score were not predictive of RVF in this dataset (hemoglobin, p=0.3, right atrial pressure to pulmonary capillary wedge pressure ratio, p=0.4). The area under the curve for EUROMACS Right-Sided Heart Failure Risk Score to predict RVF was 58% (95 % CI 52-66%). Conclusion: The EUROMACS Right-Sided Heart Failure Risk Score had poor discrimination in this LVAD dataset. These findings further emphasize the difficulty of predicting RVF after LVAD placement. Further work is required to enhance our understanding pre- LVAD right ventricular physiology and to accurately risk stratify patients.