Case Series Defining Role of External Chest Compressions (ECC) in Patients with Ventricular Assist Device (VAD)

S126 Journal of Cardiac Failure Vol. 21 No. 8S August 2015 Table 1. Multivariable regression models describing the associations of FEV1 and FVC with Hemodynamics

FEV1

PA systolic, mm Hg PA diastolic, mm Hg PA mean, mm Hg PA capacitance, mL/mm Hg PVR, WU PCWP, mm Hg

FVC

Beta Coefficient

P value

Beta Coefficient

P value

-4.95 -2.83 -3.54 0.64 -0.47 -2.06

!.001 !.001 !.001 !.001 !.001 .002

-5.06 -2.4 -3.28 0.69 -0.42 -2.08

!.001 !.001 !.001 !.001 !.001 !.001

Inventory Anxiety subscale (BSIANX), respectively. Physical and affective symptoms were clustered separately using latent mixture modeling and then compared using cross classification modeling and traditional comparative statistics (i.e. student’s t, Kendall’s tau-b and chi-square tests). Results: The average age of the sample (n5146) was 57.1612.7 years and most were male (68.7%). A majority of subjects were classified as NYHA Class III HF (56.7%) and most had non-ischemic etiology (64.7%). Two physical symptom clusters (severe physical (25.3%) and mild physical (74.7%); dyspnea t517.35, p!0.001; wake disturbances t52.40, p!0.05) and two affective symptom clusters (severe affective (15.1%) and mild affective (84.9%); depression t57.10, p!0.001; anxiety t514.6, p!0.001) were identified in a model with good fit (entropy50.89; posterior probabilities $ 86%). Subjects with severe physical symptoms were more likely to have severe than mild affective symptoms, and those with mild physical symptoms were more likely to have mild than severe affective symptoms (c2530.74, p!0.001; tau b50.46). Conclusions: There is a strong association between physical and affective symptom clusters in HF that may be helpful in understanding common pathophysiological mechanisms that underlie both types of symptoms and/or sequential processes that lead to the co-occurrence of physical and affective symptomatology among adults with moderate to advanced HF.

310 The Importance of Defining Red Blood Cell Mass in the Management of Volume Overload Chronic Systolic Heart Failure Wayne L. Miller; Mayo Clinic, Rochester, MN Introduction: The contribution of red blood cell mass (RBCM) to volume overload in decompensated chronic systolic heart failure (DCHF) is generally not considered in management strategies. With plasma volume (PV) expansion, it becomes difficult to differentiate true anemia from dilution-related “anemia” or even RBC polycythemia based upon peripheral hemoglobin (Hb) values alone. The objective of this study was to assess the contribution of RBCM to volume overload in DCHF. Hypothesis: Our study hypothesis was that patients with DCHF and clinically determined volume overload would demonstrate significant variability in RBC profiles with a high prevalence of PV dilution-related “anemia” with low peripheral Hb values but normal RBCM. Methods: Using quantitative blood volume analysis (BVA), we evaluated the contribution of RBCM to intravascular volume overload, and the reliability of peripheral Hb to reflect RBC and PV volume status in patients hospitalized for DCHF. Results: Of 32 hospitalized patients prospectively evaluated, 19 met W.H.O. criteria for anemia based upon peripheral Hb. With BVA, however, only 4 patients had true anemia (low Hb and low quantitated RBCM) with 6 demonstrating dilution-related “anemia” (low Hb and normal RBCM with PV expansion), and 9 showing the paradox of RBC polycythemia but with dilution-related “anemia” (low peripheral Hb, excess RBCM, and marked PV expansion). The remaining 13/ 32 patients had normal range Hb values but demonstrated both excess RBCM and PV expansion. Overall, 27/32 patients were hypervolemic by quantitated total blood volume (+43623% above expected normal volume). Conclusion: Patients with DCHF demonstrate marked variability in RBC profiles. RBC polycythemia was common (66%), but frequently concealed by marked PV expansion. Peripheral Hb values were often misleading in identifying true RBC status. The findings support the concept that the quantitation of RBCM and PV can identify individual volume profiles which can guide appropriate management. Key Words: chronic heart failure, volume overload, quantitative volume analysis, red blood cell mass.

314 Pre-discharge Bedside Exercise Gas Exchange Measurements Predict 30 Day Heart Failure Patient Readmissions Gregory D. Lewis1, Ashley Dress1, Gregory A. Ewald2, Jean Flanagan2, Peter Eckman3, Aaron Eisman1, Jennifer Nelson3, Dean MacCarter4, Abraham Kocheril5; 1Massachusetts General Hospital, Boston, MA; 2Washington University, St. Louis, MO; 3Universtiy of Minnesota, Minneapolis, MN; 4Shape Medical Systems, St. Paul, MN; 5University of Illinois, Champaign, IL Introduction: Thirty day hospital readmissions for heart failure (HF) are associated with high morbidity, mortality and costs. Based on evidence relating a growing array of submaximum exercise gas exchange (Gx) measurements to outcomes in HF we hypothesized that submaximum Gx testing at the time of discharge would be an effective tool to identify which patients have high risk of readmission. Methods: Patients hospitalized for acute decompensated HF (N550, mean age 65614; 78% male) from 3 participating centers who met inclusion criteria (ageO 18, NYHA II-IV chronic HF, and capable of exercise) provided informed consent were enrolled in the study. Subjects performed submax exercise on the day of hospital discharge. Heart and respiratory rate, Gx and O2 saturation were monitored continuously during a 6 min protocol consisting of 2 min of rest, 3 min of step exercise and 1 minute of recovery. A 6- parameter multimetric Shape Score consisting of resting and exercise delta ETCO2, VE slope and O2 uptake efficiency slope (OUES), pulmonary capacitance (GxCap), and end exercise SaO2 were computed. RER, HR, VO2, and O2 pulse were also assessed during rest and exercise. Results: The overall readmission (RA) rate for those Shape tested was 11 of 50 or 22%. Comparing those HF patients who were RA within 30 days vs. those who were not readmitted (NRA), volitional effort, based on peak RER, was equivalent between groups (0.946.07 and 0.946.10, respectively, p5.99). Patients with RA had higher Shape Scores than the NRA group (2.461.0 vs. 1.161.1, p! .005). Individual gas exchange parameters known to prognosticate in patients with chronic HF also tended to be more impaired in the RA group (Table, i.e. lower achieved VO2, higher VE/VCO2 slope, lower OUES). Conclusion: In this pilot study, exercise Gx using a simple, 6 min. bedside step protocol prior to discharge offers an objective means to predict likelihood

Table 1. Gas exchange variables at the time of discharge

Study group 30 day readmit N5 11 No 30 day readmit N539

Shape Multivariate Composite Score 2.461.0 p5.002 1.161.1

VO2 peak

VE/VCO2 slope

GxCAP peak

OUES

DETCO2

End exercise SaO2

9.461.5 p5.024 11.162.8

41.6616.7 NS 35.4610.4

3636208 NS 4326163

1.126.34 p50.06 1.426.51

-1.063.8 NS -.4463.0

9165 NS 9364

313 Identifying a Strong Association Between Physical and Affective Symptom Clusters in Heart Failure Quin E. Denfeld, James O. Mudd, Shirin O. Hiatt, Jill M. Gelow, Christopher V. Chien, Christopher S. Lee; Oregon Health & Science University, Portland, OR Introduction: The syndrome of heart failure (HF) is a constellation of symptoms. How physical and affective symptoms cluster together in HF, however, is not well understood. Hypothesis: There is a strong association between physical symptom clusters and affective symptom clusters among adults with moderate to advanced HF. Methods: This was a secondary analysis of data collected during a prospective cohort study of symptoms among adults with moderate to advanced HF. Physical symptoms of dyspnea and wake disturbances were measured with the Heart Failure Somatic Perception Scale Dyspnea subscale (HFSPS-D) and the Epworth Sleepiness Scale (ESS), respectively. Affective symptoms of depression and anxiety were measured with the Patient Health Questionnaire-9 (PHQ-9) and the Brief Symptom

for 30 day readmission in patients hospitalized with ADHF. A multi-metric Shape Gx score that integrates sub-maximum exercise Gx parameters outperforms individual Gx variables in predicting hospital readmission. While larger, definitive studies are required, bedside measurement of Gx in HF patients may represent an inexpensive, non-invasive practical clinical tool to track functional status and to effectively indentify HF patients at risk for readmission.

315 Case Series Defining Role of External Chest Compressions (ECC) in Patients with Ventricular Assist Device (VAD) Bhaskar Arora, Jonathan Hammond, Nicole Chomick, Tari Devoe, Nicole Huhn, Jason Gluck; Hartford Hospital, Hartford, CT Introduction: The prevalence of patients with end stage heart failure is increasing with more patients receiving VAD therapy. There is paucity of

The 19th Annual Scientific Meeting evidence looking at optimal resuscitation strategies for patients with VAD and this isn’t addressed by the current resuscitation guidelines. However, the protocol at most institutions discourages use of ECC in patients with VAD. This deviation from conventional resuscitation algorithm is largely driven by the concern that chest compression could dislodge the VAD inflow cannula, especially early on after implantation. We present a case series of 4 patients at our institution that underwent chest compression during CPR. Hypothesis: ECC may be a safe and effective resuscitation tool in patients with VAD. A VAD that is functioning during cardiac arrest could potentially provide adequate cardiac output (C.O). However, if there is clinical evidence of circulatory collapse (mean arterial pressure below 40 mmHg) ECC may prove beneficial in restoring perfusion. We hypothesize using end tidal CO2, a surrogate for C.O, to direct initiation of ECC. An ETCO2 value of less than 20mmHg can be used to direct ECC in patients with VAD. A higher ETCO2 would suggest adequate perfusion pressure is maintained by VAD and may forgo need for ECC. Methods: This case series was performed at a single North American tertiary medical center. Clinical data was gathered by review of hospital chart and emergency medical services (EMS) documents. Autopsy data was used to verify integrity of VAD after ECC. Results: We present the data on four patients with left ventricular assist device (LVAD) who underwent CPR. Three out of these four patients received ECC. ROSC was established in two patients. All LVADs were heart mate II and were implanted at our institution. All four were destination therapy. One of the patients had a recent VAD exchange due to pump failure. Cause of arrest was cardiac in three patients and primary respiratory in one patient. Autopsy was performed in three of these four patients who had received ECC and the VAD circuit was intact in all including a fresh implant. The fourth patient who didn’t receive ECC had primary respiratory failure and didn’t require ECC based on ETCO2 value of higher than 20mmHg. This patient had successful resuscitation. Conclusions: Based on our experience with these four patients with LVAD, one of whom was a new implant, we suggest that ECC can be safely performed in this population. Chest compression may not be necessary in all VAD patients during cardio pulmonary Table 1.

Age Type of Patient (yrs) Gender LVAD 1

77

Male

HM II

2 3 4

56 80 80

Male Female Male

HM II HM II HM II

Cause of Days Heart on Cause Failure support of death



HFSA

S127

arrest and should be dictated by the measurement of ETCO2. More evidence is needed to consolidate these recommendations.

317 Prognostic Value of a 6-Minute Walk Test in Patients Undergoing Percutaneous Coronary Intervention: A Prospective Study Bhavin C. Patel, Siddharth A. Wayangankar, Udho Thadani, Pedro Lozano, Faisal Latif, Daniel Zhao, Cheuk Leung, Tarun W. Dasari; University of Oklahoma Health Sciences Center, Oklahoma City, OK Background: 6 Minute Walk Distance (6MWD) is a well-validated prognostic tool in heart failure. However its utility in post percutaneous coronary intervention (PCI) patients remains unknown. Methods: We conducted a prospective study (N5212) from July 2010-October 2011 wherein patients underwent a 6-minute walk test (N5176) within 2 weeks of PCI (for acute coronary syndrome (ACS), stable angina and abnormal non-invasive stress test). The primary endpoint was major adverse cardiac events (MACE)-death, ACS and HF admission, within one year post PCI. ROC curves were used to determine the predictability of 6MWD on MACE. Youden Index was applied on the ROC curve to measure the effectiveness of 6MWD to classify patients with MACE. Results: 98% of the subjects were male. Mean age was 64.96 8.8 yrs. and major co-morbidities were hypertension (88%), diabetes (45%) and dyslipidemia (88%). 176 (83%) patients had 6MWD and clinical follow up data available. In the overall population one year adverse event rates were: MACE (22%), ACS (18%), HF admission (4%), and death (3%). 6MWD had an AUC of 0.58, indicating that 6MWD may be a poor predictor of MACE. However the 6MWD was shorter for patients who had MACE (293 vs 326 meters, p50.038). Among patients with previous history of HF (N550): 8(21%) had MACE. 6MWD in this group had an AUC of 0.64. For the end-point of HF admission during the follow up, the AUC was 0.78, suggestive of good predictive power (Figure 1, panel A&B). Using this curve for HF admissions, a cut off of 335 m was derived. Patients who achieved ! 335m(6MWD) had a greater probability of having HF admission although this did not reach statistical significance (Odds ratio (0.44; 95% CI 0.037-5.38). Conclusion: 6MWD could be a simple and reliable tool to identify a high-risk group of patients post PCI, especially those with previous HF. However, larger adequately powered studies are needed to confirm these findings.

Non ischemic

1357 Hypovolemic Shock Non ischemic 126 Uncertain Non Ischemic 1707 Uncertain Ischemic 97 Respiratory failure

Table 2. Patient outcomes

Patient

Cardiac arrest type

ECC performed

ETCO2 (mmHg)

ROSC

Autopsy LVAD intact LVAD intact LVAD intact NA

1

Aystole

Yes

15

Yes

2

Yes

NA

No

3

Ventricular Fibrillation Asystole

Yes

5

No

4

PEA

No

36

Yes

Figure 1.

Figure 1.

318 Peripartum Cardiomyopathy Network: Medication and Device Therapy Use in the First Year Kismet Rasmusson1, Dennis McNamara2, Deborah Budge1, Abdallah Kfoury1, Uri Elkayam3, Michael Givertz4, Richard Sheppard5, Greg Ewald6, Eileen Hsich7, Kalgi Modi8, Rami Alharethi1; 1Intermountain Heart Institute, Salt Lake City, UT; 2 Univesity of Pittsburgh, Pittsburgh, PA; 3University of Southern California, Los Angeles, CA; 4Brigham and Women’s Hospital, Boston, MA; 5Jewish General, Montreal, QC, Canada; 6Washington University, St. Louis, MO; 7Cleveland Clinic, Cleveland, OH; 8Louisiana State University, Shreveport, LA Background: While guideline directed medical therapy (GDMT) is well established for systolic dysfunction, little is known about its long-term use in patients with Peripartum Cardiomyopathy (PPCM). This study was undertaken to review heart failure (HF) medication and internal cardiovertor defibrillator (ICD) use in a study of 100 patients with PPCM. Methods: The Peripartum Cardiomyopathy Network (PCN) is a previously described network with pooled data of 100 prospectively studied females with PPCM from 30 centers across the U.S. There were no specific protocols for starting or stopping GDMT. Data were analyzed using simple statistics. Baseline was defined as entry into the study (within 2 months of diagnosis), followed by 6- and 12-month data. Results: Of 100 women enrolled in the PCN, 74 had medication- and 76 had echo- documentation at one year (Table 1). At 12 months, survival was 98%, 4 patients received an LVAD, 6 patients wore a Life Vest &/or had ICD implantation, and 77% had recovered