Atrial Tachyarrhythmias among Patients on Continuous Flow LVAD Support: Incidence, Prevalance and Clinical Outcomes

The 17th Annual Scientific Meeting



S17

HFSA

Neurohormones/Cytokines 043 Atrial Tachyarrhythmias among Patients on Continuous Flow LVAD Support: Incidence, Prevalance and Clinical Outcomes Christopher M. Bianco, Valeria Duarte, Deepak Pattanshetty, Matthew Bunte, Maria Mountis, Cantillon J. Daniel; Cleveland Clinic, Cleveland, OH Introduction: Atrial tachyarrhythmias, including atrial fibrillation (AF) and atrial flutter (AFL), are common among patients on LVAD support. However, the incidence, prevalence and influence on clinical outcomes remains poorly characterized. Objective/Hypothesis: To define the clinical characteristics and compare outcomes among patients with and without atrial tachyarrhythmias on continuous flow LVAD support. AF/AFL patients are hypothesized to demonstrate worse outcomes. Methods: Multi-variable analysis of Cleveland Clinic registry of Heart Mate II (HMII) LVAD recipients between 2007 and August 2012 including atrial arrhythmia data pre and post LVAD, survival outcomes and stroke/TIA events. Results: Among 252 pts (Age 54.4 6 13.8, 79% male), the AF prevalence is 140/252 (56%), and AFL prevalence 33/252 (13%) pts. New AF during LVAD support occurred in 42/154 (27%) pts and new AFL in 17/237 (7%) pts. In comparing patients with AF/AFL (n5149/252, 59%) to those without AF/AFL (n5103/252, 41%), the TIA/stroke event rates were similar (AF/AFL n515/149, 10% vs. none n517/103, 17%; p50.10) with fewer warfarin ineligible pts in AF/AFL group (AF/AFL n511/149, 7% vs. none 12/103, 12%; p50.05) and similar target INRs above the nominal 1.7-2.2 range (Above-nominal INR: AF/AFL 45/138, 35% vs. none 30/81, 33%, p50.8). Survival outcomes over median 305 days follow-up (25th/75th quartiles 108 days, 661 days) were similar between the groups (KM curve figure 1, log-rank p50.9). Conclusion: Atrial tachyarrhythmias in the form of AF and AFL are common among patients on LVAD support, but do not appear to influence overall survival and yield similar stroke/TIA event rates.

vs RVF: 1.3560.58, P!0.01). RA pressure and RA to pulmonary capillary wedge pressure ratio (RA/PCWP) were also associated with RVF (Table 1). Other previously identified markers of RV function including RV stroke work index, mean pulmonary artery pressure, qualitative RV dysfunction (RVD) by 2D echo, and laboratory parameters were not associated with RVF (Table 1). After adjusting for RA pressure in a multivariate model, PaPi remained an independent predictor of RVF. A trend toward reduced survival (censored for transplant) at 180 days was observed in the RVF group (No RVF: 86% vs. RVF: 67%, P50.059). Conclusions: PaPi is a readily available and easily derived baseline variable associated with RVF following LVAD surgery. A larger cohort is necessary to identify optimal PaPi thresholds with which to guide clinical decision making was well as to evaluate model performance of a risk prediction rule incorporating PaPi. Table 1. Baseline variables of patients undergoing LVAD surgery

Age (years) Gender (%male) Destination Therapy (%) Ischemic CM (%) BUN Cr AST INR Moderate-severe RVD (%) HR (bpm) MAP (mmHg) RA (mmHg) mPAP (mmHg) PCWP (mmHg) CI (L/min/m2) TPG (mmHg) RA/PCWP RVSWI PAPI

All patients (n5104)

No RVF (n583)

RVF (n521)

P values

55.9612.1 79 25

55.8612.7 80 25

56.269.6 76 24

0.90 0.77 1.00

39 29618 1.4460.59 776285 1.5260.79 24

43 30618 1.4860.63 776315 1.5560.88 24

24 29616 1.3260.43 736169 1.4160.43 24

0.14 0.88 0.29 0.96 0.53 1.00

91615 7668 1265 3569 2467 2.4560.68 11.665.9 0.5060.20 4.5263.13 2.4361.36

92616 7668 1064 3669 2467 2.4260.66 11.665.4 0.4360.14 4.4562.50 2.7161.36

89611 7568 1765 3369 2267 2.5560.76 11.867.9 0.7960.13 4.7964.76 1.3560.58

0.45 0.51 !0.0001 0.29 0.17 0.44 0.87 !0.0001 0.67 !0.0001

045 Device Exchange and Thrombolytic Therapy for Left Ventricular Assist Device Thrombosis Kevin Morine, Michael Kiernan, Navin Kapur, Jenica Upshaw, Duc Pham, David Denofrio; Tufts Medical Center, Boston, MA

044 Pulmonary Artery Pulsatility Index as a Novel Marker of Right Ventricular Failure Following LVAD Surgery Kevin Morine, Michael Kiernan, Navin Kapur, Robert Baumgartner, Duc Pham, David Denofrio; Tufts Medical Center, Boston, MA Background: The significance of reduced pulse pressure in the right-sided circulation as a marker of right ventricular dysfunction prior to LVAD surgery remains uncertain. We evaluated the pulmonary artery pulsatility index (PaPi), a recently described hemodynamic metric, as a baseline predictor of post-operative RV failure following LVAD surgery. Methods: We conducted a retrospective review of 104 consecutive LVAD implantations at our hospital. Demographic, clinical, hemodynamic and echocardiographic data were evaluated for their association with the development of RVF. RVF was defined as need for RVAD or inotrope dependence for greater than 14 days. PaPi was calculated as [(systolic pulmonary artery pressure-diastolic pulmonary artery pressure)/right atrial (RA) pressure]. Univariate analysis was performed to identify baseline predictors of RVF. Multivariate logistic regression was used to adjust for baseline RA pressure. Results: RVF occurred in 21 of 104 patients (20%); all cases were due to prolonged inotropes. PaPi was lower among patients with RVF compared to those without (no RVF: mean 2.716 SD1.36

Background: Optimal management strategies for continuous-flow LVAD thrombosis (LVAD-T) have not been determined. We describe our experience with 11 pts managed for LVAD-T receiving device exchange and/or thrombolytic therapy (TPA). Methods: A chart review of pts managed for LVAD-T from 1/1/2010 to 4/1/2013 was performed. Thrombus was suspected in the setting of unexplained hemolysis with lactate dehydrogenase (LDH) O4 times ULN (700 IU/L). Treatment options for LVAD-T were made on a case-by-case basis with involvement of the patient and caregivers. Pts were considered for urgent LVAD exchange or TPA if they were hemodynamically unstable. LVAD exchange was also considered for cardioembolic events or failure to respond to TPA. Pts were otherwise treated first with a trial of antithrombotic therapy with escalation to VAD exchange or TPA if conservative therapy failed. Success of TPA was defined as thrombus resolution without serious adverse event or need for LVAD exchange. Success of VAD exchange was considered as long-term survival. Among pts receiving TPA, alteplase was administered (0.75-1 mg/min) either intravenously (n51; 100 mg) or via an intracavitary approach (n54; 38-90 mg). Results: 20 of 116 pts presented with LVAD-T. 11 of 20 pts were managed with LVAD exchange and/or TPA. 5 pts underwent LVAD exchange, 5 pts were given TPA and 1 pt given TPA required exchange for recurrent LVAD-T. In addition to hemolysis, presentation included heart failure symptoms (5), VAD abnormalities (8), or thromboembolic event (3). Mean peak LDH was 15606900 IU/L. Two pts presented with cardiogenic shock and underwent urgent LVAD exchange. 9 pts were initially managed with antithrombotic therapy alone (unfractionated heparin, eptifibatide, or bivalirudin). Due to non-response, 5 of these pts were transitioned to TPA and 4 underwent VAD exchange. Adverse events included 1 intracranial hemorrhage (TPA), 1 gastrointestinal bleed with transfusion (exchange) and 2 mediastinal hematomas (TPA-1, exchange-1). Among 6 pts initially undergoing LVAD exchange, 4 (67%) were transplanted or are alive on LVAD support and 2 died. There was 1 recurrence at 58 days in the new LVAD, treated with bivalirudin until transplant. Among 5 pts receiving TPA, 2 died (40%) and 3 were discharged. There was one recurrence at 13 days requiring exchange. The overall success of TPA at 30 days was 40% (2 pts). Conclusions: LVAD-T is associated with significant morbidity. In our