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Chloride Homeostasis in End Stage Heart Failure and LVAD Recipients
S382
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
palliative measure or until eligible for advanced therapies). Continuous inotrope infusion exposes patients to increased risk of arrhythmias and mortality. It is unknown whether such patients can be weaned off inotropic support in an outpatient setting. Methods: In a single-center observational study of patients admitted with ADHF between 2016-2018, we studied demographics, clinical history, physical exam data, and laboratory data. We determined functional status and compliance with medical therapies of patients who were successfully weaned off inotropes. Creatinine, electrolytes, vital signs, and physical exam findings were followed weekly/biweekly during weaning and followed post-wean for ≥60 days. Results: 9 patients (mean age 49 y; 5 males) were successfully weaned off inotropes in an outpatient setting. All had been discharged home on milrinone or dobutamine infusion. Only 1 patient had ischemic cardiomyopathy; 2 had required mechanical support during hospitalization. Median length of stay after inotrope initiation was 8 days with median 78 days on inotropes prior to weaning. 6 patients were started on sacubitril/valsartan, which was uptitrated during weaning, of whom 3 tolerated the maximum dose. The other patients were uptitrated on angiotensin converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARB). 60 days post-wean, all 9 patients reported doing well with NYHA Class IIIa (n=5), Class IV (n=1), and Class II (n=3) symptoms. On longitudinal follow-up, 1 patient was hospitalized 1year post-wean, was subsequently restarted on inotropes and required heart transplantation. Conclusion: With close monitoring and gentle uptitration of afterloadreducing agents, it is feasible to wean patients with ADHF off inotropes in an outpatient setting.
Figure 1. During a mean follow-up of 4§2 months, 7 patients (30%) were admitted (4 patients for CV problems and 3 for non-CV). 16 patients died (14 CV deaths and 2 non-CV). Of those, twelve patients (75%) died at home or in long-stay centers Conclusion: The multidisciplinary care for end-stage HF was feasible and well accepted for the patients and their relatives. The majority of the patientes knew the severity of the disease and the poor prognosis and received treatments for non-CVsymptoms. A high percentage of patients died outside the hospital. The high short-term mortality probably suggests that palliative care should be considered earlier in endstage HF.
963 Multidisciplinary Care for End-Stage HF. How to Improve Care? S. Mirabet,1 A. Pascual,2 P. Fluvia,3 M. Pirla,1 N. Mesado,1 I. Lumillo,1 E. Villegas,4 M. Llauger,5 and E. Roig.1 1Cardiology, Hospital Sant Pau, Barcelona, Spain; 2Palliative Care, Hospital Sant Pau, Barcelona, Spain; 3Cardiology, Hospital Josep Trueta, Girona, Spain; 4 Intern Medicine, Creu Roja, Barcelona, Spain; and the 5Primary Care, Sant Pau, Barcelona, Spain. Purpose: Palliative care in advanced heart failure (HF) patients is not standardized. Our aim was to assess the feasibility of a multidisciplinary team in patients with advanced HF. Methods: Observational, prospective, single-center study performed in outpatients with advanced HF excluded for heart transplantation or LVAD. The multidisciplinary team includes a cardiologist and nurse specialized in advanced HF, a palliative care physician, case manager nurses and primary care physicians. Patients were identified as palliative according to the clinical clues reported in 2013 ACC/AHA guidelines. All patients and their relatives accepted to be included in the program. We evaluated the level of knowledge of the end-stage phase of the disease, the main non-cardiovascular symptoms and treatments, number of hospital admissions, time to death and place of death. Results: From October 2016 to March 2018, 23 patients were included. Age 77 § 5 years, 92% men;they had high comorbidity (Barthel 78.6 § 15) and dependency (Charlson 6 § 1.1). Ten patients had HFpEF.All patients knew the severity of their illness and 65% considered the possibility of dying soon. More than 70% of the patients had non cardiovascular (CV) symptoms. Main symptoms and palliative treatments are shown in
964 Chloride Homeostasis in End Stage Heart Failure and LVAD Recipients K. Stawiarski,1 O. Agboola,2 D. Jacoby,2 L. Bellumkonda,2 T. Ahmad,2 L. Sugeng,2 M. Chen,2 G. McCloskey,2 A. Geirsson,2 M. Anwar,2 and P. Bonde.2 1Yale New Haven Health Bridgeport Hospital, New Haven, CT; and the 2Yale School of Medicine, New Haven, CT. Purpose: Abnormal chloride homeostasis is associated with worse survival in patients with chronic heart failure. Maladaptive neurohormonal
Abstracts responses and chronic diuretic use deplete serum chloride levels. However, the prognostic implications of serum chloride levels in LVAD patients is not fully elucidated. Our objective was to determine the effect of preLVAD hypochloremia on long term survival in LVAD patients. Methods: We performed a retrospective analysis of all 166 LVAD implants between January 2011 and June 2018 at a single center. Patients were classified into either [hypochloremia (serum chloride<98mEq/L) (Group A) n=88 or normochloremia (98 -106mEq/L) (Group B) n=70] based on admission serum chloride levels. A total of eight patients were excluded: seven with chloride >106mEq/L and one with incomplete data. Median chloride levels were used to assess the impact of LVAD therapy. Unadjusted and adjusted cox models were used to examine for association between hypochloremia and 2-year all-cause mortality. We compared survival between both groups using Kaplan-Meir plot and log-rank statistics. Results: Chloride levels in group A normalized over three months and peaked at 24 months with a 7mEq/l rise from baseline. Group B levels remained normal with a marginal 0.5mEq/L rise from baseline at 24 months. No significant association between hypochloremia and survival was found [unadjusted HR= 1.01 (0.62 - 1.64), p=0.98] [adjusted HR= 0.88 (0.53 - 1.44), p=0.60]. Conclusion: LVAD therapy normalizes chloride homeostasis via cardiorenal axis and stresses its prognostic value. Survival in the long run may be multi-factorial besides chloride levels alone.
S383 965 Home Inotropic Therapy as a Bridge and as Destination: Intended and Unintended Outcomes in a Single Center Contemporary Cohort C.S. Grubb, M.S. Bohnen, A. Kleet, V.K. Topkara, A.R. Garan, R. Bijou, M.S. Maurer, H. Garan and M. Farr. Columbia University Medical Center, New York, NY. Purpose: Continuous home inotropic therapy (HIT) is used as a bridge to heart transplant (BTT), ventricular assist device (BTVAD), decision regarding advanced therapies (BTD), for optimization of oral therapy and inotrope wean (OMT) and for palliative care (PC). While HIT may reduce symptoms, improve functional status and allow time for advanced care decisions, contemporary data on whether the goal of therapy was achieved are limited. Methods: This is a single center, retrospective study of hospitalized patients initiated on HIT from 1/1/2013 - 7/1/2017. Outcomes included whether the intended goal of HIT was achieved, need for re-hospitalization within 1 year of HIT initiation and mortality. Results: 241 patients (mean age 60.7§10.2 years; 71% male) were discharged on HIT (90% milrinone). Etiology was ischemic in 36.1%. Mean EF was 19.4§10.2%, PCWP 24.0§8.6 mmHg and Fick CI 1.6§0.4 L/min/m2 prior to HIT initiation. At 1 year, 99% of BTT and BTVAD patients reached OHT, VAD or were alive on HIT (Table 1). For BTT, 23.5% reached OHT but 28.4% required VAD. For BTVAD, 82.9% reached VAD within 1 year, with mean time to VAD of 79§79 days. For BTD, survival was 64% at 1 year, indicating that co-morbidities or other characteristics contributed to difficult decision-making and moving these patients to a definitive pathway. For OMT, 30% of patients were weaned off inotropes and 3 died within 1 year. For PC, only 25% had palliative care consults prior to discharge. Interestingly, 8 patients were alive for > 3 years on HIT (1BTT, 4 OMT, and 3 PC). Conclusion: HIT is a reasonable therapy for some patients with advanced heart failure, although unplanned re-hospitalization remains high. HIT represents a step toward a VAD decision and in some cases a viable BTT pathway. HIT for PC is a growing strategy as more time with greater quality might be afforded. For OMT or BTD, there is more uncertainty regarding the safety and efficacy of HIT. Further work in a multicenter registry is needed to better understand the role of HIT.
Table 1
Alive at 1 year Intended (or end of % goal reached Goal of HIT n follow up) at 1 year
% with planned re-hospitalization % with (VAD or Transplant unplanned re-hospitalization Surgery)
BTT BTVAD BTD
81 98.8% 70 100.0% 11 81.8%
76.5% 95.7% 81.8%
16.0% 54.3% 27.3%
OMT
30 90.0%
43.3%
0.0%
PC
49 77.8%
53.1%
−
23.5% 82.9% 90.9% Decision Made 30.0% Off inotropes −
966 Bariatric Surgery in Patients with Systolic and Diastolic Heart Failure: Insights from the Nationwide Inpatient Sample V. Blumer,1 M. Ortiz,2 G.A. Hernandez,1 and A. Vest.3 1University of Miami, Miami, FL; 2University of Iowa, Iowa City, IA; and the 3Tufts Medical Center, Boston, MA. Purpose: Obesity is an established risk factor for the development of heart failure (HF). Weight loss after bariatric surgery may have a positive impact in long-term HF outcomes; however, there is scarcity of data exploring the safety of bariatric surgery in this population. Methods: Using the 2010-2015 Nationwide Inpatient Sample database, we identified the overall demographic characteristics and incidence of in-hospital complications in HF patients after bariatric procedures. Multivariate logistic regression was used to determine the relationship between HF and in-hospital outcomes. Results: A total of 963,603 patients underwent bariatric procedures. Of these, 3,427 (0.36%) had systolic HF (sHF) and 6,327 (0.66%) had diastolic HF
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
palliative measure or until eligible for advanced therapies). Continuous inotrope infusion exposes patients to increased risk of arrhythmias and mortality. It is unknown whether such patients can be weaned off inotropic support in an outpatient setting. Methods: In a single-center observational study of patients admitted with ADHF between 2016-2018, we studied demographics, clinical history, physical exam data, and laboratory data. We determined functional status and compliance with medical therapies of patients who were successfully weaned off inotropes. Creatinine, electrolytes, vital signs, and physical exam findings were followed weekly/biweekly during weaning and followed post-wean for ≥60 days. Results: 9 patients (mean age 49 y; 5 males) were successfully weaned off inotropes in an outpatient setting. All had been discharged home on milrinone or dobutamine infusion. Only 1 patient had ischemic cardiomyopathy; 2 had required mechanical support during hospitalization. Median length of stay after inotrope initiation was 8 days with median 78 days on inotropes prior to weaning. 6 patients were started on sacubitril/valsartan, which was uptitrated during weaning, of whom 3 tolerated the maximum dose. The other patients were uptitrated on angiotensin converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARB). 60 days post-wean, all 9 patients reported doing well with NYHA Class IIIa (n=5), Class IV (n=1), and Class II (n=3) symptoms. On longitudinal follow-up, 1 patient was hospitalized 1year post-wean, was subsequently restarted on inotropes and required heart transplantation. Conclusion: With close monitoring and gentle uptitration of afterloadreducing agents, it is feasible to wean patients with ADHF off inotropes in an outpatient setting.
Figure 1. During a mean follow-up of 4§2 months, 7 patients (30%) were admitted (4 patients for CV problems and 3 for non-CV). 16 patients died (14 CV deaths and 2 non-CV). Of those, twelve patients (75%) died at home or in long-stay centers Conclusion: The multidisciplinary care for end-stage HF was feasible and well accepted for the patients and their relatives. The majority of the patientes knew the severity of the disease and the poor prognosis and received treatments for non-CVsymptoms. A high percentage of patients died outside the hospital. The high short-term mortality probably suggests that palliative care should be considered earlier in endstage HF.
963 Multidisciplinary Care for End-Stage HF. How to Improve Care? S. Mirabet,1 A. Pascual,2 P. Fluvia,3 M. Pirla,1 N. Mesado,1 I. Lumillo,1 E. Villegas,4 M. Llauger,5 and E. Roig.1 1Cardiology, Hospital Sant Pau, Barcelona, Spain; 2Palliative Care, Hospital Sant Pau, Barcelona, Spain; 3Cardiology, Hospital Josep Trueta, Girona, Spain; 4 Intern Medicine, Creu Roja, Barcelona, Spain; and the 5Primary Care, Sant Pau, Barcelona, Spain. Purpose: Palliative care in advanced heart failure (HF) patients is not standardized. Our aim was to assess the feasibility of a multidisciplinary team in patients with advanced HF. Methods: Observational, prospective, single-center study performed in outpatients with advanced HF excluded for heart transplantation or LVAD. The multidisciplinary team includes a cardiologist and nurse specialized in advanced HF, a palliative care physician, case manager nurses and primary care physicians. Patients were identified as palliative according to the clinical clues reported in 2013 ACC/AHA guidelines. All patients and their relatives accepted to be included in the program. We evaluated the level of knowledge of the end-stage phase of the disease, the main non-cardiovascular symptoms and treatments, number of hospital admissions, time to death and place of death. Results: From October 2016 to March 2018, 23 patients were included. Age 77 § 5 years, 92% men;they had high comorbidity (Barthel 78.6 § 15) and dependency (Charlson 6 § 1.1). Ten patients had HFpEF.All patients knew the severity of their illness and 65% considered the possibility of dying soon. More than 70% of the patients had non cardiovascular (CV) symptoms. Main symptoms and palliative treatments are shown in
964 Chloride Homeostasis in End Stage Heart Failure and LVAD Recipients K. Stawiarski,1 O. Agboola,2 D. Jacoby,2 L. Bellumkonda,2 T. Ahmad,2 L. Sugeng,2 M. Chen,2 G. McCloskey,2 A. Geirsson,2 M. Anwar,2 and P. Bonde.2 1Yale New Haven Health Bridgeport Hospital, New Haven, CT; and the 2Yale School of Medicine, New Haven, CT. Purpose: Abnormal chloride homeostasis is associated with worse survival in patients with chronic heart failure. Maladaptive neurohormonal
Abstracts responses and chronic diuretic use deplete serum chloride levels. However, the prognostic implications of serum chloride levels in LVAD patients is not fully elucidated. Our objective was to determine the effect of preLVAD hypochloremia on long term survival in LVAD patients. Methods: We performed a retrospective analysis of all 166 LVAD implants between January 2011 and June 2018 at a single center. Patients were classified into either [hypochloremia (serum chloride<98mEq/L) (Group A) n=88 or normochloremia (98 -106mEq/L) (Group B) n=70] based on admission serum chloride levels. A total of eight patients were excluded: seven with chloride >106mEq/L and one with incomplete data. Median chloride levels were used to assess the impact of LVAD therapy. Unadjusted and adjusted cox models were used to examine for association between hypochloremia and 2-year all-cause mortality. We compared survival between both groups using Kaplan-Meir plot and log-rank statistics. Results: Chloride levels in group A normalized over three months and peaked at 24 months with a 7mEq/l rise from baseline. Group B levels remained normal with a marginal 0.5mEq/L rise from baseline at 24 months. No significant association between hypochloremia and survival was found [unadjusted HR= 1.01 (0.62 - 1.64), p=0.98] [adjusted HR= 0.88 (0.53 - 1.44), p=0.60]. Conclusion: LVAD therapy normalizes chloride homeostasis via cardiorenal axis and stresses its prognostic value. Survival in the long run may be multi-factorial besides chloride levels alone.
S383 965 Home Inotropic Therapy as a Bridge and as Destination: Intended and Unintended Outcomes in a Single Center Contemporary Cohort C.S. Grubb, M.S. Bohnen, A. Kleet, V.K. Topkara, A.R. Garan, R. Bijou, M.S. Maurer, H. Garan and M. Farr. Columbia University Medical Center, New York, NY. Purpose: Continuous home inotropic therapy (HIT) is used as a bridge to heart transplant (BTT), ventricular assist device (BTVAD), decision regarding advanced therapies (BTD), for optimization of oral therapy and inotrope wean (OMT) and for palliative care (PC). While HIT may reduce symptoms, improve functional status and allow time for advanced care decisions, contemporary data on whether the goal of therapy was achieved are limited. Methods: This is a single center, retrospective study of hospitalized patients initiated on HIT from 1/1/2013 - 7/1/2017. Outcomes included whether the intended goal of HIT was achieved, need for re-hospitalization within 1 year of HIT initiation and mortality. Results: 241 patients (mean age 60.7§10.2 years; 71% male) were discharged on HIT (90% milrinone). Etiology was ischemic in 36.1%. Mean EF was 19.4§10.2%, PCWP 24.0§8.6 mmHg and Fick CI 1.6§0.4 L/min/m2 prior to HIT initiation. At 1 year, 99% of BTT and BTVAD patients reached OHT, VAD or were alive on HIT (Table 1). For BTT, 23.5% reached OHT but 28.4% required VAD. For BTVAD, 82.9% reached VAD within 1 year, with mean time to VAD of 79§79 days. For BTD, survival was 64% at 1 year, indicating that co-morbidities or other characteristics contributed to difficult decision-making and moving these patients to a definitive pathway. For OMT, 30% of patients were weaned off inotropes and 3 died within 1 year. For PC, only 25% had palliative care consults prior to discharge. Interestingly, 8 patients were alive for > 3 years on HIT (1BTT, 4 OMT, and 3 PC). Conclusion: HIT is a reasonable therapy for some patients with advanced heart failure, although unplanned re-hospitalization remains high. HIT represents a step toward a VAD decision and in some cases a viable BTT pathway. HIT for PC is a growing strategy as more time with greater quality might be afforded. For OMT or BTD, there is more uncertainty regarding the safety and efficacy of HIT. Further work in a multicenter registry is needed to better understand the role of HIT.
Table 1
Alive at 1 year Intended (or end of % goal reached Goal of HIT n follow up) at 1 year
% with planned re-hospitalization % with (VAD or Transplant unplanned re-hospitalization Surgery)
BTT BTVAD BTD
81 98.8% 70 100.0% 11 81.8%
76.5% 95.7% 81.8%
16.0% 54.3% 27.3%
OMT
30 90.0%
43.3%
0.0%
PC
49 77.8%
53.1%
−
23.5% 82.9% 90.9% Decision Made 30.0% Off inotropes −
966 Bariatric Surgery in Patients with Systolic and Diastolic Heart Failure: Insights from the Nationwide Inpatient Sample V. Blumer,1 M. Ortiz,2 G.A. Hernandez,1 and A. Vest.3 1University of Miami, Miami, FL; 2University of Iowa, Iowa City, IA; and the 3Tufts Medical Center, Boston, MA. Purpose: Obesity is an established risk factor for the development of heart failure (HF). Weight loss after bariatric surgery may have a positive impact in long-term HF outcomes; however, there is scarcity of data exploring the safety of bariatric surgery in this population. Methods: Using the 2010-2015 Nationwide Inpatient Sample database, we identified the overall demographic characteristics and incidence of in-hospital complications in HF patients after bariatric procedures. Multivariate logistic regression was used to determine the relationship between HF and in-hospital outcomes. Results: A total of 963,603 patients underwent bariatric procedures. Of these, 3,427 (0.36%) had systolic HF (sHF) and 6,327 (0.66%) had diastolic HF