- Email: [email protected]
Bridging the Gap to LVAD Recovery and Explantation
S132 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 diuretics may be safer and still efficacious. Larger prospective studies are needed to confirm these results.
360 Clinical Outcomes of Elderly Patients with Heart Failure Janna C. Beavers1, Caitlin C. Akerman1, Donald F. Gabel2, Stuart D. Russell3; 1 WakeMed Health & Hospitals, Raleigh, NC; 2Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC; 3Duke University Hospital, Raleigh, NC Introduction: The incidence of elderly patients with heart failure continues to increase. Unfortunately, most clinical trials evaluating the medications currently used for the treatment of heart failure did not include patients over the age of 80 and the benefits of using these medications in this patient population are unclear. We sought to evaluate the outcomes of elderly patients with heart failure. Methods: This cohort study was conducted in patients discharged after a heart failure admission with HFrEF. We followed all patients over the age of 80 between February 1, 2015 and December 31, 2017 and matched them with a similar group between 60-79. Patients were included following discharge with a diagnosis of heart failure with documented follow-up within the health system. Groups were matched based on gender, ejection fraction, and month of admission. The primary outcome was a composite of death, hospitalization, or ED visit within one month of hospital discharge. The elderly cohort (age 80 years) was evaluated further in a regression analysis to determine if there were predictive characteristics for the occurrence of outcomes. Results: There were 194 HFrEF patients included in the study, 97 in each cohort (60-79 years vs 80 years old). Groups were fairly balanced in terms of baseline characteristics, with differences in ejection fraction, weight, race, and diastolic blood pressure. One-month outcomes were similar between the two cohorts: composite including death, hospitalization, or ED visit (13.4 vs. 19.6%, p=0.25), death/hospice (0% vs 1.0%, p=1.0), and hospitalization/ED visits (13.4% vs 18.6%, p=0.33). Patients in the elderly cohort who met the primary outcome had a lower ejection fraction (25.3% vs. 29%, p=0.036), were less likely to have diabetes (2.6% vs. 30.7%, p=0.0391), and less likely to be an ACE inhibitor/ARB/ARNi at hospital discharge (32.6% vs. 59.0%, p=0.032). A preliminary regression model included all baseline characteristics and found significant differences based on ejection fraction (p=0.039), African American race (p=0.025), hyperlipidemia (p=0.042), weight (p=0.025), heart rate (p=0.037), and beta blocker use at discharge (p=0.049). Conclusions: There are no differences in the outcomes of death/hospitalization/ED visits at 30 days between patients aged 60-79 years and 80 years. Elderly patients should be included in clinical trials evaluating heart failure medications as age alone does not appear to be predictive of a worse outcome.
untimely death. Conclusions: The goal of this project was to identify patients who have the potential for bridge to recovery. We want to focus our attention on this option to establish a bridge to recovery program. We hope to improve the quality of life of these patients given we can avoid life threatening complications and improve their overall quality of life that can be similar to a normal healthy adult after explantation. A bridge to recovery program also has the potential to benefit resource utilization for our patients and institution.
362 Human Immunodeficiency Virus Infection and Risk of Heart Failure Readmissions Sadeer G. Al-Kindi, Nour Tashtish, David T. Brouch, Chris T. Longenecker; University Hospitals Cleveland Medical Center, Cleveland, OH Background: Human Immunodeficiency Infection (HIV) is associated with increased risk for heart failure (HF). Outcomes of HF in people living with HIV (PLHIV) are unknown. We sought to identify the risk of HF readmissions (30 and 90 days) among PLHIV vs uninfected controls admitted with HF. Methods: Using the 2016 national readmission database, we identified all patients ( 18 years) who were discharged alive with a primary diagnosis of HF (ICD10 I50.xx) with or without secondary diagnosis of HIV (ICD 10 Z21, B20, O98.7, or B97.35). Propensity score matching (PSM) was used to match PLHIV with controls (1:1) based on 45 patient characteristics (demographics, hospitalization characteristics, and comorbidities). Cox regression models were used to compare rates of HF readmission (primary ICD10 I50.xx) within 30 and 90 days after discharge from index HF hospitalization. Results: A total of 312,264 patients with HF were identified, of whom 1,112 (0.4%) had HIV. After PSM, 1,112 PLHIV were matched with 1,112 uninfected controls. The standard mean difference for each variable was less than 10% post-matching. Overall, HF readmission rates were 11.2% and 19.2% at 30 and 90 days, respectively. The two groups (PLHIV and controls) were not different statistically with respect to all 45 covariates. Compared with controls, PLHIV had higher risk of HF readmission within 30 days (HR 1.45, 95% CI: 1.13-1.87, P=0.004) and 90 days (HR 1.41, 95% CI 1.16-1.71, P<0.001), figure. This risk was consistent across types of HF (systolic, diastolic), P for interaction = 0.95 and 0.70 for 30 day-readmissions and 90-day readmissions, respectively. Conclusions: In this propensity-matched national cohort of patients admitted with HF, patients with HIV appear to have increased risk of HF readmissions compared with uninfected controls at 30 days and 90 days.
361 Bridging the Gap to LVAD Recovery and Explantation Karlee K. Hoffman, Manreet Kanwar; Allegheny Health Network, Pittsburgh, PA Introduction: Left ventricular assist device (LVAD) implantation continues to occur at an exceedingly high rate due to the donor and supply mismatch when it comes to heart transplantation. LVADs however do not come without risk and have high rates of significant bleeding, stroke, pump thrombosis and infection. Most of the clinical and research efforts thus far have been focused on LVAD insertion with the goal of destination therapy or as a bridge to transplant. The goal of bridge to recovery has often been underestimated despite multiple studies showing reverse remodeling of the myocardium. Success rates with regards to device explantation varies from <1%8%. Prospective studies with nonischemic patients have shown success rates as high as 60% recovery. Hypothesis: The goal of our study was to analyze all the patients that have received an LVAD at Allegheny General Hospital from the years 20062017 (n=277). By looking at different echocardiographic parameters, we identified all patients with the potential for bridge to recovery. We suspected that of our previous LVAD patients, we were missing this responder population who had the potential for LVAD explantation. Methods: With our institutions IRB approval, we retrospectively collected echocardiographic data on all LVAD implantations. We focused specifically on the LVEDD (left ventricular end diastolic diameter) and LVEF (left ventricular ejection fraction). We defined responders as those patients with an LVEDD <60 mm and LVEF >40% at some point post LVAD implantation. We analyzed echo parameters at pre-LVAD, 1, 3, 6, and 12 months status post LVAD implantation. Results: We identified 16 responders (5.7%). Of these 16 responders, 9 were male (56.3%) and 7 were female (43.7%). Of these responders, 50% of them were classified as INTERMACS 1 at the time of LVAD implant. Of these implantations, 69% were Heartmate 2. The average age of the responder patient was 63 years old. Of note, the average responder Pre-LVAD LVEDD was 59 mm and LVEF 15%. Subsequently at 1 month, the average LVEDD was 45 mm and 20%, 3 month LVEDD 42 mm and LVEF 25%, 6 month LVEDD 43 mm and LVEF 25%, 12 month LVEDD 43.5 mm and LVEF 30%. Of the 16 responders, 1 patient proceeded to transplant despite recovery of LVEF. Of the remaining 15 responders, only 5 patients were explanted with 1 patient requiring subsequent listing for transplant. By identifying this patient population of responders, it allows us to aggressively pursue further explantation options for these patients in the future and avoid unnecessary cardiac transplantation and ultimately catastrophic LVAD complications leading to an
363 Use of Potentially Harmful Drugs among Medicare Beneficiaries with Heart Failure and Reduced Ejection Fraction: Impact on Readmissions and Mortality Paulino Alvarez, Alexandros Briasoulis, Saket Girotra, Chakradhari Inampudi, Amgad Mentias, Mary Vaughan-Sarrazin; University of Iowa, Iowa CIty, IA Background: Multiple cardiac and non-cardiac drugs have the potential to exacerbate heart failure (HF). Information regarding prevalence of their use among elderly patients with HF is scarce. Objectives: This study sought to analyze the prevalence
360 Clinical Outcomes of Elderly Patients with Heart Failure Janna C. Beavers1, Caitlin C. Akerman1, Donald F. Gabel2, Stuart D. Russell3; 1 WakeMed Health & Hospitals, Raleigh, NC; 2Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC; 3Duke University Hospital, Raleigh, NC Introduction: The incidence of elderly patients with heart failure continues to increase. Unfortunately, most clinical trials evaluating the medications currently used for the treatment of heart failure did not include patients over the age of 80 and the benefits of using these medications in this patient population are unclear. We sought to evaluate the outcomes of elderly patients with heart failure. Methods: This cohort study was conducted in patients discharged after a heart failure admission with HFrEF. We followed all patients over the age of 80 between February 1, 2015 and December 31, 2017 and matched them with a similar group between 60-79. Patients were included following discharge with a diagnosis of heart failure with documented follow-up within the health system. Groups were matched based on gender, ejection fraction, and month of admission. The primary outcome was a composite of death, hospitalization, or ED visit within one month of hospital discharge. The elderly cohort (age 80 years) was evaluated further in a regression analysis to determine if there were predictive characteristics for the occurrence of outcomes. Results: There were 194 HFrEF patients included in the study, 97 in each cohort (60-79 years vs 80 years old). Groups were fairly balanced in terms of baseline characteristics, with differences in ejection fraction, weight, race, and diastolic blood pressure. One-month outcomes were similar between the two cohorts: composite including death, hospitalization, or ED visit (13.4 vs. 19.6%, p=0.25), death/hospice (0% vs 1.0%, p=1.0), and hospitalization/ED visits (13.4% vs 18.6%, p=0.33). Patients in the elderly cohort who met the primary outcome had a lower ejection fraction (25.3% vs. 29%, p=0.036), were less likely to have diabetes (2.6% vs. 30.7%, p=0.0391), and less likely to be an ACE inhibitor/ARB/ARNi at hospital discharge (32.6% vs. 59.0%, p=0.032). A preliminary regression model included all baseline characteristics and found significant differences based on ejection fraction (p=0.039), African American race (p=0.025), hyperlipidemia (p=0.042), weight (p=0.025), heart rate (p=0.037), and beta blocker use at discharge (p=0.049). Conclusions: There are no differences in the outcomes of death/hospitalization/ED visits at 30 days between patients aged 60-79 years and 80 years. Elderly patients should be included in clinical trials evaluating heart failure medications as age alone does not appear to be predictive of a worse outcome.
untimely death. Conclusions: The goal of this project was to identify patients who have the potential for bridge to recovery. We want to focus our attention on this option to establish a bridge to recovery program. We hope to improve the quality of life of these patients given we can avoid life threatening complications and improve their overall quality of life that can be similar to a normal healthy adult after explantation. A bridge to recovery program also has the potential to benefit resource utilization for our patients and institution.
362 Human Immunodeficiency Virus Infection and Risk of Heart Failure Readmissions Sadeer G. Al-Kindi, Nour Tashtish, David T. Brouch, Chris T. Longenecker; University Hospitals Cleveland Medical Center, Cleveland, OH Background: Human Immunodeficiency Infection (HIV) is associated with increased risk for heart failure (HF). Outcomes of HF in people living with HIV (PLHIV) are unknown. We sought to identify the risk of HF readmissions (30 and 90 days) among PLHIV vs uninfected controls admitted with HF. Methods: Using the 2016 national readmission database, we identified all patients ( 18 years) who were discharged alive with a primary diagnosis of HF (ICD10 I50.xx) with or without secondary diagnosis of HIV (ICD 10 Z21, B20, O98.7, or B97.35). Propensity score matching (PSM) was used to match PLHIV with controls (1:1) based on 45 patient characteristics (demographics, hospitalization characteristics, and comorbidities). Cox regression models were used to compare rates of HF readmission (primary ICD10 I50.xx) within 30 and 90 days after discharge from index HF hospitalization. Results: A total of 312,264 patients with HF were identified, of whom 1,112 (0.4%) had HIV. After PSM, 1,112 PLHIV were matched with 1,112 uninfected controls. The standard mean difference for each variable was less than 10% post-matching. Overall, HF readmission rates were 11.2% and 19.2% at 30 and 90 days, respectively. The two groups (PLHIV and controls) were not different statistically with respect to all 45 covariates. Compared with controls, PLHIV had higher risk of HF readmission within 30 days (HR 1.45, 95% CI: 1.13-1.87, P=0.004) and 90 days (HR 1.41, 95% CI 1.16-1.71, P<0.001), figure. This risk was consistent across types of HF (systolic, diastolic), P for interaction = 0.95 and 0.70 for 30 day-readmissions and 90-day readmissions, respectively. Conclusions: In this propensity-matched national cohort of patients admitted with HF, patients with HIV appear to have increased risk of HF readmissions compared with uninfected controls at 30 days and 90 days.
361 Bridging the Gap to LVAD Recovery and Explantation Karlee K. Hoffman, Manreet Kanwar; Allegheny Health Network, Pittsburgh, PA Introduction: Left ventricular assist device (LVAD) implantation continues to occur at an exceedingly high rate due to the donor and supply mismatch when it comes to heart transplantation. LVADs however do not come without risk and have high rates of significant bleeding, stroke, pump thrombosis and infection. Most of the clinical and research efforts thus far have been focused on LVAD insertion with the goal of destination therapy or as a bridge to transplant. The goal of bridge to recovery has often been underestimated despite multiple studies showing reverse remodeling of the myocardium. Success rates with regards to device explantation varies from <1%8%. Prospective studies with nonischemic patients have shown success rates as high as 60% recovery. Hypothesis: The goal of our study was to analyze all the patients that have received an LVAD at Allegheny General Hospital from the years 20062017 (n=277). By looking at different echocardiographic parameters, we identified all patients with the potential for bridge to recovery. We suspected that of our previous LVAD patients, we were missing this responder population who had the potential for LVAD explantation. Methods: With our institutions IRB approval, we retrospectively collected echocardiographic data on all LVAD implantations. We focused specifically on the LVEDD (left ventricular end diastolic diameter) and LVEF (left ventricular ejection fraction). We defined responders as those patients with an LVEDD <60 mm and LVEF >40% at some point post LVAD implantation. We analyzed echo parameters at pre-LVAD, 1, 3, 6, and 12 months status post LVAD implantation. Results: We identified 16 responders (5.7%). Of these 16 responders, 9 were male (56.3%) and 7 were female (43.7%). Of these responders, 50% of them were classified as INTERMACS 1 at the time of LVAD implant. Of these implantations, 69% were Heartmate 2. The average age of the responder patient was 63 years old. Of note, the average responder Pre-LVAD LVEDD was 59 mm and LVEF 15%. Subsequently at 1 month, the average LVEDD was 45 mm and 20%, 3 month LVEDD 42 mm and LVEF 25%, 6 month LVEDD 43 mm and LVEF 25%, 12 month LVEDD 43.5 mm and LVEF 30%. Of the 16 responders, 1 patient proceeded to transplant despite recovery of LVEF. Of the remaining 15 responders, only 5 patients were explanted with 1 patient requiring subsequent listing for transplant. By identifying this patient population of responders, it allows us to aggressively pursue further explantation options for these patients in the future and avoid unnecessary cardiac transplantation and ultimately catastrophic LVAD complications leading to an
363 Use of Potentially Harmful Drugs among Medicare Beneficiaries with Heart Failure and Reduced Ejection Fraction: Impact on Readmissions and Mortality Paulino Alvarez, Alexandros Briasoulis, Saket Girotra, Chakradhari Inampudi, Amgad Mentias, Mary Vaughan-Sarrazin; University of Iowa, Iowa CIty, IA Background: Multiple cardiac and non-cardiac drugs have the potential to exacerbate heart failure (HF). Information regarding prevalence of their use among elderly patients with HF is scarce. Objectives: This study sought to analyze the prevalence