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Analysis of Post-LVAD Clinical Pathways
S352
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
Methods: Between 2010 and 2015, 110 patients(pts) required a LVAD, 21 of whom had documented pulmonary hypertension (PH) per right heart catheterization and at least moderate degree of RV dysfunction per standard echocardiographic criteria within 2 weeks of LVAD implant. Follow-up demographic, laboratory and echocardiographic assessment of RV function and pulmonary arterial systolic pressure (PASP) was performed on 2 separate visits 4 weeks to 6 months after LVAD implant. Results: Of the 21 pts identified with pre-LVAD PH and RV dysfunction, 12 pts exhibited RV functional recovery. Between the groups that showed improvement and did not, there was no difference in terms of gender, race, age, LVAD type (Heartmate II or HeartWare), total cardiopulmonary bypass time, pulmonary vasodilatory therapy (sildenafil or tadalafil), or presence of pre-capillary PH at implant. Furthermore, both groups showed similar degree of LV unloading post-implant as suggested by normalization in both PASP and LV end diastolic diameter. In the RV improvement group, there was significantly higher BMI (30±8kg/m2 vs 23±4kg/m2, p= 0.03) and lower pre-implant creatinine (1.2±0.3 mg/dL vs 2.0±0.9mg/dL, p= 0.03). Other laboratory parameters such as hemoglobin, total bilirubin, AST, ALT and albumin showed no significant difference. Conclusion: In LVAD pts with pre-operative RV dysfunction and PH, factors that correlate with RV improvement include higher BMI and lower preimplant creatinine. Larger studies are needed to validate our findings.
worsening renal function and show the impact of various potential interventions and comorbidities on that pathway. In other words this tool would map out the likely course for patients presenting with advanced symptoms in a manner that the patient can visually relate to. Conclusion: We believe that this analysis will be useful to guide clinical management based on the most likely outcomes of interventions. This information could be helpful for decision-making prior to LVAD implantation. 1( 077) Patients with End-Stage Heart Failure: Two Takes on Health Engagement L.C. Lohmueller ,1 C.K. McIlvennan,2 M. Kanwar,3 J.F. Antaki.1 1Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA; 2Cardiovascular Institute, University of Colorado, Denver, Denver, CO; 3Cardiology, Allegheny General Hospital, Pittsburgh, PA. Purpose: The decision by a patient to receive a left ventricular assist device (LVAD) requires awareness of the severity of their heart failure, changes in lifestyle, and the risks of adverse events. Decision support tools can help navigate this maze of information. The goal of this study was to investigate the needs of potential users to inform the design of a decision aid. Methods: We surveyed 57 patients from two clinical sites using a 44-item questionnaire related to: interaction with their cardiologist, interest/comfort with receiving information related to their condition, and familiarity with data visualization. The sampled patients were 82% male, predominantly NYHA class III (N= 28), with an average age of 60 (29-79). Data was analyzed using Bayesian search methodology. Results: Several variables were shown to be inter-related (Figure 1). The probability of requesting medical records was directly related to comfort talking with their physician. The amount of time spent with their physician was positively correlated with their ability to understand visualization of data. Interestingly, satisfaction with time spent with the physician was not connected to the amount of time spent. Finally, patients less comfortable with their physicians were less likely to ask for their electronic healthcare records. Conclusion: While the majority of patients in this pilot study were amenable to accessing more information about their health and treatment options, a non-negligible minority had a different outlook. Both categories of patients need to be considered when designing a decision aid for LVAD implantation.
1( 076) Analysis of Post-LVAD Clinical Pathways F. Movahedi ,1 L. Carey,2 Y. Zhang,3 R. Padman,4 J. Antaki,5 M. Kanwar.6 1Electrical Engineering, University of Pittsburgh, Pittsburgh, PA; 2Biomedical Engineering, University of Pittsburgh, Pittsburgh, PA; 3Heinz College, Carnegie Mellon University, Pittsburgh, PA; 4University of Texas at Austi, Pittsburgh, PA; 5Mechanical Engineering, University of Pittsburgh, Pittsburgh, PA; 6Allegheny General Hospital, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA. Purpose: As LVADs are becoming more commonly used for destination therapy, increasing focus is directed to the clinical course after hospital discharge. This study aims to identify and classify the most common clinical pathways of patients after receiving an LVAD. Methods: Sequential clinical data of 17100 patients from the time of LVAD implantation to termination of support were abstracted from the INTERMACS registry between 2010 and 2015. The data was comprised of a combination of (1) clinical follow-up visits and (2) adverse events. At each point in time, the data were organized according to: (a) diagnosis, (b) lab values, (c) hemodynamics, (d) treatments & medications. The sequences of patients’ visits were differentiated into distinct categories using hierarchical clustering based on longest common distances of sub-sequences. Then, to extract the most common clinical pathways for each subgroup, the sequences of visits were represented as Markov chains by connecting the transitions between states (clinical visits). These pathways are then depicted graphically as a branching “road map” with varying width, indicating probability, and encoded by color, indicating outcome. Results: The result is to transforms a potentially daunting collection of registry data into a practical set of common clinical pathways. As an example, this care pathway would project the likely clinical course of a 60 year old male presenting in clinic for evaluation of ACC/AHA stage D heart failure but is relatively well compensated and tolerating medical therapy or a similar patient who is now intolerant to evidence based heart failure regimen but has
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
Methods: Between 2010 and 2015, 110 patients(pts) required a LVAD, 21 of whom had documented pulmonary hypertension (PH) per right heart catheterization and at least moderate degree of RV dysfunction per standard echocardiographic criteria within 2 weeks of LVAD implant. Follow-up demographic, laboratory and echocardiographic assessment of RV function and pulmonary arterial systolic pressure (PASP) was performed on 2 separate visits 4 weeks to 6 months after LVAD implant. Results: Of the 21 pts identified with pre-LVAD PH and RV dysfunction, 12 pts exhibited RV functional recovery. Between the groups that showed improvement and did not, there was no difference in terms of gender, race, age, LVAD type (Heartmate II or HeartWare), total cardiopulmonary bypass time, pulmonary vasodilatory therapy (sildenafil or tadalafil), or presence of pre-capillary PH at implant. Furthermore, both groups showed similar degree of LV unloading post-implant as suggested by normalization in both PASP and LV end diastolic diameter. In the RV improvement group, there was significantly higher BMI (30±8kg/m2 vs 23±4kg/m2, p= 0.03) and lower pre-implant creatinine (1.2±0.3 mg/dL vs 2.0±0.9mg/dL, p= 0.03). Other laboratory parameters such as hemoglobin, total bilirubin, AST, ALT and albumin showed no significant difference. Conclusion: In LVAD pts with pre-operative RV dysfunction and PH, factors that correlate with RV improvement include higher BMI and lower preimplant creatinine. Larger studies are needed to validate our findings.
worsening renal function and show the impact of various potential interventions and comorbidities on that pathway. In other words this tool would map out the likely course for patients presenting with advanced symptoms in a manner that the patient can visually relate to. Conclusion: We believe that this analysis will be useful to guide clinical management based on the most likely outcomes of interventions. This information could be helpful for decision-making prior to LVAD implantation. 1( 077) Patients with End-Stage Heart Failure: Two Takes on Health Engagement L.C. Lohmueller ,1 C.K. McIlvennan,2 M. Kanwar,3 J.F. Antaki.1 1Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA; 2Cardiovascular Institute, University of Colorado, Denver, Denver, CO; 3Cardiology, Allegheny General Hospital, Pittsburgh, PA. Purpose: The decision by a patient to receive a left ventricular assist device (LVAD) requires awareness of the severity of their heart failure, changes in lifestyle, and the risks of adverse events. Decision support tools can help navigate this maze of information. The goal of this study was to investigate the needs of potential users to inform the design of a decision aid. Methods: We surveyed 57 patients from two clinical sites using a 44-item questionnaire related to: interaction with their cardiologist, interest/comfort with receiving information related to their condition, and familiarity with data visualization. The sampled patients were 82% male, predominantly NYHA class III (N= 28), with an average age of 60 (29-79). Data was analyzed using Bayesian search methodology. Results: Several variables were shown to be inter-related (Figure 1). The probability of requesting medical records was directly related to comfort talking with their physician. The amount of time spent with their physician was positively correlated with their ability to understand visualization of data. Interestingly, satisfaction with time spent with the physician was not connected to the amount of time spent. Finally, patients less comfortable with their physicians were less likely to ask for their electronic healthcare records. Conclusion: While the majority of patients in this pilot study were amenable to accessing more information about their health and treatment options, a non-negligible minority had a different outlook. Both categories of patients need to be considered when designing a decision aid for LVAD implantation.
1( 076) Analysis of Post-LVAD Clinical Pathways F. Movahedi ,1 L. Carey,2 Y. Zhang,3 R. Padman,4 J. Antaki,5 M. Kanwar.6 1Electrical Engineering, University of Pittsburgh, Pittsburgh, PA; 2Biomedical Engineering, University of Pittsburgh, Pittsburgh, PA; 3Heinz College, Carnegie Mellon University, Pittsburgh, PA; 4University of Texas at Austi, Pittsburgh, PA; 5Mechanical Engineering, University of Pittsburgh, Pittsburgh, PA; 6Allegheny General Hospital, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA. Purpose: As LVADs are becoming more commonly used for destination therapy, increasing focus is directed to the clinical course after hospital discharge. This study aims to identify and classify the most common clinical pathways of patients after receiving an LVAD. Methods: Sequential clinical data of 17100 patients from the time of LVAD implantation to termination of support were abstracted from the INTERMACS registry between 2010 and 2015. The data was comprised of a combination of (1) clinical follow-up visits and (2) adverse events. At each point in time, the data were organized according to: (a) diagnosis, (b) lab values, (c) hemodynamics, (d) treatments & medications. The sequences of patients’ visits were differentiated into distinct categories using hierarchical clustering based on longest common distances of sub-sequences. Then, to extract the most common clinical pathways for each subgroup, the sequences of visits were represented as Markov chains by connecting the transitions between states (clinical visits). These pathways are then depicted graphically as a branching “road map” with varying width, indicating probability, and encoded by color, indicating outcome. Results: The result is to transforms a potentially daunting collection of registry data into a practical set of common clinical pathways. As an example, this care pathway would project the likely clinical course of a 60 year old male presenting in clinic for evaluation of ACC/AHA stage D heart failure but is relatively well compensated and tolerating medical therapy or a similar patient who is now intolerant to evidence based heart failure regimen but has