- Email: [email protected]
756 Can Right Ventricular Failure Associated with LVAD Insertion Be Avoided?
S258
The Journal of Heart and Lung Transplantation, Vol 31, No 4S, April 2012
ventricular ejection fraction (LVEF) ⬍0.35 and the use of inotropes were judged as signs of possible LVAD indication. Lastly, in-hospital and 1-year outcome was analyzed and compared with outcome of LVAD implanted from 2007 to 2010 (C-LVAD). Results: 1244 pts were hospitalized for HF in one year. 191 were excluded due to age and 270 for other causes. 59 out of the remaining 783 pts had LVEF ⬍0.35 and received inotropes, but only 38 (3%) were considered appropriate potential LVAD candidates after hospital chart review. Inhospital mortality was 5/38 (13%). Within 1-year, 8 pts underwent to heart transplant and 3 to LVAD with 10 surviving; 8/16 (50%) of medically managed pts died. In-hospital mortality after 2007-2010 C-LVAD implantation was 5/27 (18.5%). In 1-year, 3 pts were transplanted and only 1/20 pts remaining on LVAD died. Conclusions: Pts with HF characterized by low LVEF and the need for inotropes have a poor 1-year prognosis on medical therapy and would probably benefit from LVAD. The proportion of pts potentially candidates for LVAD is low with respect to the total population of HF, but the absolute number is high due to the prevalence of this syndrome. 755 Reduced Handgrip Strength as a Marker of Patient Frailty Predicts Worse Survival after Implantation of a Left Ventricular Assist Device C.J. Chung,1 O. Ferreira,1 C. Wu,1 H. Akashi,1 T.S. Kato,1 H. Takayama,2 Y. Naka,2 D.M. Mancini,1 P.C. Schulze.1 1Center for Advanced Cardiac Care, Columbia University Medical Center, New York, NY; 2Department of Surgery, Columbia University Medical Center, New York, NY. Purpose: Derangement of skeletal muscle function and metabolism in advanced heart failure (HF) contributes to patient frailty, and has been linked to morbidity and mortality. We evaluated grip strength as a marker of frailty and predictor of outcomes in patients with advanced HF undergoing left ventricular assist device (LVAD) implantation. Methods and Materials: Grip strength was measured pre-operatively (2.9 ⫾ 6.5 days prior to surgery) in 33 HF patients (63.3 ⫾ 10.0 yrs, BMI 27.8 ⫾ 4.5 kg/m2). Subjects performed three consecutive maximal isometric contractions with the non-dominant hand and averages were taken. Clinical data were gathered from institutional medical records. Baseline grip strength was correlated with clinical outcomes.
756 Can Right Ventricular Failure Associated with LVAD Insertion Be Avoided? R.M. Adamson,1 J. Chammas,1 V. Norman,1 B. Jaski,2 P. Hoagland,2 S. Chillcott,3 M. Stahovich,3 W.P. Dembitsky.1 1Cardiothoracic Surgery, Sharp Memorial Hospital, San Diego, CA; 2Cardiology, Sharp Memorial Hospital, San Diego, CA; 3Nursing, Sharp Memorial Hospital, San Diego, CA. Purpose: The reported incidence of right heart failure (RHF) and the need for an RVAD varies widely between institutions but is always associated with increased morbidity and mortality. Methods and Materials: All HeartMate I (HMI) 92 patients (since 1991) were compared to all HeartMate II (HMII) 152 patients (since 2005) to assess differences in RHF immediately post LVAD implant. Although the surgical team has remained constant throughout the study period, management protocols and implantation techniques have evolved to now include universal; aggressive correction of associated native heart abnormalities, stringent pre-operative hemodynamic and fluid resuscitation, coagulopathy correction, routine intraoperative hemoconcentration, chemical RVAD inotropic support, continuous prophylactic inhaled Nitric Oxide (iNO) during the implant and oral Sidenafil. Results: In the group of HMI patients 24% (22/92) required a transitional RVAD (mean 45.5 mins.) to exit cardiopulmonary bypass (CPB) vs. 1% (1/152) of HMII patients (120 minutes, P⬍.05), 12% HMI patients (11/92) required prolonged RVAD support (mean 5 days) vs. 1% (2/152) HMII patients (mean 3 days, P⬍.05), 18% of HMI patients (17/92) did not require an RVAD but left the operating room with an open chest for improved right ventricular function vs. 1% (2/152) HMII patients (mean 3 days, P⬍.05). Overall RHF was manifested in 54.3% (50/92) of HMI patients vs. 3.2% (5/152) HMII patients (P⬍.01) It could be suggested that RHF was undertreated in the HMII series although 95% (144/152) of patients were discharged from the hospital at a mean of 22.3 ⫹/⫺ 13.9 days and overall survival was 82% and 69% at 1 and 3 years. There were only 3 patients that required inotropic support longer than 7 days and there were no right RHF related deaths. Conclusions: The necessity of RVAD utilization in the last 6 years associated with HMII implants is extremely low, ⬍1%. Although these improvements may be due to HMII vs. HMI devices or differences in patient selection, we feel the improvement is more dependent upon operator management techniques. 757 The Relation of Body Size and Outcome in Patients Using Continuous Flow Left Ventricular Assist Devices A. Mano, J.J. Teuteberg, C.A. Bermudez, J.K. Bhama, D.M. McNamara, R. Ramani, M. Simon, R.L. Kormos. Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA.
Results: Patients had a mean grip strength of 28.2 ⫾ 11.7 lbs (nondominant hand). Those below the 25th percentile of grip strength (⬍20.0 lbs) had higher post-operative mortality compared to those above the 25th percentile (58.3% vs 14.3%, p⫽0.0286). They also had higher all-cause mortality (31.4% vs 13.2%, p⫽0.0401) during LVAD support (mean 155.3 ⫾ 112.9 days). Patients with grip strength ⬍20.0 lbs had lower pre-operative hemoglobin (mean 10.6 ⫾ 1.7 g/dL, p⫽0.0056). There were no differences in pre-operative white blood cell count, platelets, percentage of lymphocytes, serum albumin, total and direct bilirubin, and sodium (all p⬎0.05). Conclusions: Reduced grip strength of the non-dominant hand to ⬍25% percentile predicts early post-operative and all-cause mortality of HF patients undergoing LVAD implantation. Assessing the pre-operative grip strength as an indicator of patient frailty might improve patient selection and overall outcome following LVAD surgery.
Purpose: We investigate the relation between body size and the outcome in patients with continuous flow left ventricular assist devices (c-LVADs). Methods and Materials: We divided 78 patients who underwent c-LVADs implantation between December 2006 and June 2011 into three groups based on body surface area (BSA, m2) (Group1, ⬍ 1.9; Group 2, 1.9 to 2.1; Group 3, ⬎ 2.1) and compared the outcome among these three groups during mean support of 265 ⫾ 260 days. Results: There was no significant difference in the percentage of patients who received c-LVADs as destination therapy among three groups (Group 1, 2, 3; 41%, 25%, 30%; p ⫽ 0.449). Actual one year survival rate was significantly lower in Group 1 (53.7%, 81.0%, 80.5%; p ⫽ 0.0483). Patients in Group1 were a significantly higher risk of death as compared to those with Groups 2 and 3(Odds ratio [OR] 4.8, 95% confidential interval [CI] 1.31 – 17.66, OR 3.8, 95% CI 1.02 – 14.21, respectively). Patients in Group 1 experienced cerebrovascular events (41%, 14%, 13%; p ⫽ 0.026) and non-device-related infection (78%, 39%, 30%; p ⬍ 0.01) more frequently although device-related infection and sepsis were comparable among the three groups (19%, 21%, 35%; p ⫽ 0.37, 41%, 25%, 35%; p ⫽ 0.458, respectively). The requirement of right ventricular assist device (41%, 18%, 17%; p ⫽ 0.085) and bleeding requiring transfusion (59%,
The Journal of Heart and Lung Transplantation, Vol 31, No 4S, April 2012
ventricular ejection fraction (LVEF) ⬍0.35 and the use of inotropes were judged as signs of possible LVAD indication. Lastly, in-hospital and 1-year outcome was analyzed and compared with outcome of LVAD implanted from 2007 to 2010 (C-LVAD). Results: 1244 pts were hospitalized for HF in one year. 191 were excluded due to age and 270 for other causes. 59 out of the remaining 783 pts had LVEF ⬍0.35 and received inotropes, but only 38 (3%) were considered appropriate potential LVAD candidates after hospital chart review. Inhospital mortality was 5/38 (13%). Within 1-year, 8 pts underwent to heart transplant and 3 to LVAD with 10 surviving; 8/16 (50%) of medically managed pts died. In-hospital mortality after 2007-2010 C-LVAD implantation was 5/27 (18.5%). In 1-year, 3 pts were transplanted and only 1/20 pts remaining on LVAD died. Conclusions: Pts with HF characterized by low LVEF and the need for inotropes have a poor 1-year prognosis on medical therapy and would probably benefit from LVAD. The proportion of pts potentially candidates for LVAD is low with respect to the total population of HF, but the absolute number is high due to the prevalence of this syndrome. 755 Reduced Handgrip Strength as a Marker of Patient Frailty Predicts Worse Survival after Implantation of a Left Ventricular Assist Device C.J. Chung,1 O. Ferreira,1 C. Wu,1 H. Akashi,1 T.S. Kato,1 H. Takayama,2 Y. Naka,2 D.M. Mancini,1 P.C. Schulze.1 1Center for Advanced Cardiac Care, Columbia University Medical Center, New York, NY; 2Department of Surgery, Columbia University Medical Center, New York, NY. Purpose: Derangement of skeletal muscle function and metabolism in advanced heart failure (HF) contributes to patient frailty, and has been linked to morbidity and mortality. We evaluated grip strength as a marker of frailty and predictor of outcomes in patients with advanced HF undergoing left ventricular assist device (LVAD) implantation. Methods and Materials: Grip strength was measured pre-operatively (2.9 ⫾ 6.5 days prior to surgery) in 33 HF patients (63.3 ⫾ 10.0 yrs, BMI 27.8 ⫾ 4.5 kg/m2). Subjects performed three consecutive maximal isometric contractions with the non-dominant hand and averages were taken. Clinical data were gathered from institutional medical records. Baseline grip strength was correlated with clinical outcomes.
756 Can Right Ventricular Failure Associated with LVAD Insertion Be Avoided? R.M. Adamson,1 J. Chammas,1 V. Norman,1 B. Jaski,2 P. Hoagland,2 S. Chillcott,3 M. Stahovich,3 W.P. Dembitsky.1 1Cardiothoracic Surgery, Sharp Memorial Hospital, San Diego, CA; 2Cardiology, Sharp Memorial Hospital, San Diego, CA; 3Nursing, Sharp Memorial Hospital, San Diego, CA. Purpose: The reported incidence of right heart failure (RHF) and the need for an RVAD varies widely between institutions but is always associated with increased morbidity and mortality. Methods and Materials: All HeartMate I (HMI) 92 patients (since 1991) were compared to all HeartMate II (HMII) 152 patients (since 2005) to assess differences in RHF immediately post LVAD implant. Although the surgical team has remained constant throughout the study period, management protocols and implantation techniques have evolved to now include universal; aggressive correction of associated native heart abnormalities, stringent pre-operative hemodynamic and fluid resuscitation, coagulopathy correction, routine intraoperative hemoconcentration, chemical RVAD inotropic support, continuous prophylactic inhaled Nitric Oxide (iNO) during the implant and oral Sidenafil. Results: In the group of HMI patients 24% (22/92) required a transitional RVAD (mean 45.5 mins.) to exit cardiopulmonary bypass (CPB) vs. 1% (1/152) of HMII patients (120 minutes, P⬍.05), 12% HMI patients (11/92) required prolonged RVAD support (mean 5 days) vs. 1% (2/152) HMII patients (mean 3 days, P⬍.05), 18% of HMI patients (17/92) did not require an RVAD but left the operating room with an open chest for improved right ventricular function vs. 1% (2/152) HMII patients (mean 3 days, P⬍.05). Overall RHF was manifested in 54.3% (50/92) of HMI patients vs. 3.2% (5/152) HMII patients (P⬍.01) It could be suggested that RHF was undertreated in the HMII series although 95% (144/152) of patients were discharged from the hospital at a mean of 22.3 ⫹/⫺ 13.9 days and overall survival was 82% and 69% at 1 and 3 years. There were only 3 patients that required inotropic support longer than 7 days and there were no right RHF related deaths. Conclusions: The necessity of RVAD utilization in the last 6 years associated with HMII implants is extremely low, ⬍1%. Although these improvements may be due to HMII vs. HMI devices or differences in patient selection, we feel the improvement is more dependent upon operator management techniques. 757 The Relation of Body Size and Outcome in Patients Using Continuous Flow Left Ventricular Assist Devices A. Mano, J.J. Teuteberg, C.A. Bermudez, J.K. Bhama, D.M. McNamara, R. Ramani, M. Simon, R.L. Kormos. Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA.
Results: Patients had a mean grip strength of 28.2 ⫾ 11.7 lbs (nondominant hand). Those below the 25th percentile of grip strength (⬍20.0 lbs) had higher post-operative mortality compared to those above the 25th percentile (58.3% vs 14.3%, p⫽0.0286). They also had higher all-cause mortality (31.4% vs 13.2%, p⫽0.0401) during LVAD support (mean 155.3 ⫾ 112.9 days). Patients with grip strength ⬍20.0 lbs had lower pre-operative hemoglobin (mean 10.6 ⫾ 1.7 g/dL, p⫽0.0056). There were no differences in pre-operative white blood cell count, platelets, percentage of lymphocytes, serum albumin, total and direct bilirubin, and sodium (all p⬎0.05). Conclusions: Reduced grip strength of the non-dominant hand to ⬍25% percentile predicts early post-operative and all-cause mortality of HF patients undergoing LVAD implantation. Assessing the pre-operative grip strength as an indicator of patient frailty might improve patient selection and overall outcome following LVAD surgery.
Purpose: We investigate the relation between body size and the outcome in patients with continuous flow left ventricular assist devices (c-LVADs). Methods and Materials: We divided 78 patients who underwent c-LVADs implantation between December 2006 and June 2011 into three groups based on body surface area (BSA, m2) (Group1, ⬍ 1.9; Group 2, 1.9 to 2.1; Group 3, ⬎ 2.1) and compared the outcome among these three groups during mean support of 265 ⫾ 260 days. Results: There was no significant difference in the percentage of patients who received c-LVADs as destination therapy among three groups (Group 1, 2, 3; 41%, 25%, 30%; p ⫽ 0.449). Actual one year survival rate was significantly lower in Group 1 (53.7%, 81.0%, 80.5%; p ⫽ 0.0483). Patients in Group1 were a significantly higher risk of death as compared to those with Groups 2 and 3(Odds ratio [OR] 4.8, 95% confidential interval [CI] 1.31 – 17.66, OR 3.8, 95% CI 1.02 – 14.21, respectively). Patients in Group 1 experienced cerebrovascular events (41%, 14%, 13%; p ⫽ 0.026) and non-device-related infection (78%, 39%, 30%; p ⬍ 0.01) more frequently although device-related infection and sepsis were comparable among the three groups (19%, 21%, 35%; p ⫽ 0.37, 41%, 25%, 35%; p ⫽ 0.458, respectively). The requirement of right ventricular assist device (41%, 18%, 17%; p ⫽ 0.085) and bleeding requiring transfusion (59%,