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Clinical Outcomes Associated with INTERMACS Defined Right Ventricular Failure After LVAD Implantation
S100 Journal of Cardiac Failure Vol. 21 No. 8S August 2015 validation in a separate cohort will be necessary to determine generalizability, this model could provide a framework on which to personalize discussions on the risk of GIB and direct patient-specific anticoagulation strategies.
Figure 1.
231 Diagnosis of Left Ventricular Assist Device (LVAD) Pump Thrombosis Using Fibrin-Specific 99mTc Imaging Agent Gregory A. Ewald, Grace Cui, Michael Scott, Michael E. Nassif, Shane J. LaRue, Justin M. Vader, David S. Raymer, Walter Akers, Scott Silvestry, Akinobu Itoh, Samuel Achilefu, Gregory Lanza; Washington University, St. Louis, MO
232 Clinical Outcomes Associated with INTERMACS Defined Right Ventricular Failure After LVAD Implantation Brian R. Pierce, David Raymer, Anuradha Godishala, Christopher Sparrow, Michael Nassif, Shane LaRue, Gregory Ewald, Justin Vader; Barnes-Jewish Hospital, Saint Louis, MO Introduction: The INTERMACS definition of right ventricular failure (RVF) stratifies patients based on duration of inotropic therapy or RVAD implantation. RVF is described as mild, moderate, or severe based on #7, 8-14, O14 days of inotropic therapy, or RVAD implantation, respectively. We sought to evaluate clinical outcomes associated with this stratification system. Methods: We retrospectively identified 448 consecutive patients who underwent CF-LVAD implantation between 1/2005 and 9/ 2014. Cohorts were devised based on inotrope requirement of #7, 7-14, 15-21 or O21 days, or requirement for RVAD. The primary outcome was time to death from any cause. The secondary outcome was a combined end-point including allcause death, CHF rehospitalization, and GI bleeding. Results: Median follow up was 319 (126-654) days. The median days of inotropes post LVAD implantation was 8 (6-14). 35 patients required an RVAD. There were 177 patients on inotropes for #7 days, 138 for 8-14 days, 63 for 15-21 days, 35 for O21 days. The majority of patients in both groups were male (80%) and categorized with a median INTERMACS profile of 2 at the time of LVAD implant. Two-year mortality was 21% vs. 20% vs. 38% vs. 69% for patients with #7, 8-14, 15-21, and O21 days of inotropes, respectively, with no statistically significant difference between patients on inotropes for !15 days. Two-year mortality was 66% in the RVAD cohort. Cohorts with prolonged inotropic support ($15 days) or RVAD implantation had significantly higher two-year mortality, 53% vs. 21% in the #14 days of inotrope cohort, p ! 0.0001 (Figure 1). There was also an increased incidence of the combined end-point in this group (Figure 2). Conclusion: In patients with continuous-flow LVADs, days of inotropes are only significantly associated with mortality if required beyond 14 days. RVAD implantation and prolonged inotropic support are associated with a 2.5 fold increase in mortality. Defining these patients as severe RV failure versus non-severe RV failure yields a clinically significant outcome. Stratification of RV failure based on inotrope support for 0-7 or 8-14 days is not associated with long term clinical outcomes and appears unnecessary.
Background: Left Ventricular Assist Device (LVAD) pump thrombosis (PT) is a devastating complication of mechanical circulatory support. The diagnosis of LVAD thrombus is difficult in vivo, often only suggested by markers of hemolysis and echocardiographic features, which lack sensitivity. We sought to test a probe with high avidity anti-fibrin 99mTc to localize and quantify thrombus within the high shear environment of titanium axial-flow pumps. Methods: Monomeric bifunctional ligands with a fibrin-specific peptide, a short spacer, and technetium chelating amino acid sequence (F1A) were covalently inter-coupled via a 4-arm-PEG2000 tetramer to form F4A. Each was radiolabeled with 99mTc using the IsoLink procedure. We collected 20 explanted HeartMate II LVADs, of which 9 were explanted for suspected pump thrombosis and 11 were explanted during heart transplant or exchange for other complications. Ex-vivo imaging of explanted pumps was conducted in plasma using a mock circulatory loop running at 9400 RPM for 30 minutes as has previously been described. After imaging the devices were sent to the manufacturer for disassembly and thorough inspection for thrombus. Results: The majority of patients were male (85%) with a mean age of 54.1 6 9.8 and a median INTERMACS profile of 2. The median time of LVAD support prior to explant was 7.6 6 7.2 months. Of the 9 patients exchanged for suspected pump thrombosis all had undetectable haptoglobin levels and mean LDH levels of 3520 6 2596. All 9 had CT scans prior to LVAD exchange without any visualized thrombus or kinking of the inflow or outflow cannulas. Two of the pumps have been disassembled and inspected by the manufacturer. Both pumps were in patients with suspected pump thrombosis and both the pumps had thrombus found on SPECT imaging and on visual inspection (Figure 1A and 1B). Conclusions: A novel, fibrin-specific 99mTc small tetrameric probe offers the potential to detect, localize, and quantify intra-LVAD thrombus noninvasively. Once verified in a large cohort this agent offers the opportunity to diagnose LVAD pump thrombosis at an earlier stage. Definite and early diagnosis may confer therapeutic options to avoid pump failure and/or costly and morbid LVAD exchange.
Figure 1.
Figure 2.
233 Impact of Cytomegalovirus on Survival After Heart Transplant: analysis of 20,000 Patients from the UNOS Registry Data Guha Ashrith, Ahmed Daoud, Larry D. Teeter, Javier Amione-Guerra, Andrea M. Cordero-Reyes, Edward Gravis, Barry H. Trachtenberg, Arvind Bhimaraj, Osama A. Gaber, Scott Scheinin, Guillermo Torre-Amione, Jerry D. Estep; The Methodist Hospital, Houston, TX
Figure 1.
Background: Cytomegalovirus (CMV) infection has been implicated in a number of complications after heart transplant. Our study aim was to determine the effects of CMV donor-recipient status in a large cohort of patients undergoing heart
Figure 1.
231 Diagnosis of Left Ventricular Assist Device (LVAD) Pump Thrombosis Using Fibrin-Specific 99mTc Imaging Agent Gregory A. Ewald, Grace Cui, Michael Scott, Michael E. Nassif, Shane J. LaRue, Justin M. Vader, David S. Raymer, Walter Akers, Scott Silvestry, Akinobu Itoh, Samuel Achilefu, Gregory Lanza; Washington University, St. Louis, MO
232 Clinical Outcomes Associated with INTERMACS Defined Right Ventricular Failure After LVAD Implantation Brian R. Pierce, David Raymer, Anuradha Godishala, Christopher Sparrow, Michael Nassif, Shane LaRue, Gregory Ewald, Justin Vader; Barnes-Jewish Hospital, Saint Louis, MO Introduction: The INTERMACS definition of right ventricular failure (RVF) stratifies patients based on duration of inotropic therapy or RVAD implantation. RVF is described as mild, moderate, or severe based on #7, 8-14, O14 days of inotropic therapy, or RVAD implantation, respectively. We sought to evaluate clinical outcomes associated with this stratification system. Methods: We retrospectively identified 448 consecutive patients who underwent CF-LVAD implantation between 1/2005 and 9/ 2014. Cohorts were devised based on inotrope requirement of #7, 7-14, 15-21 or O21 days, or requirement for RVAD. The primary outcome was time to death from any cause. The secondary outcome was a combined end-point including allcause death, CHF rehospitalization, and GI bleeding. Results: Median follow up was 319 (126-654) days. The median days of inotropes post LVAD implantation was 8 (6-14). 35 patients required an RVAD. There were 177 patients on inotropes for #7 days, 138 for 8-14 days, 63 for 15-21 days, 35 for O21 days. The majority of patients in both groups were male (80%) and categorized with a median INTERMACS profile of 2 at the time of LVAD implant. Two-year mortality was 21% vs. 20% vs. 38% vs. 69% for patients with #7, 8-14, 15-21, and O21 days of inotropes, respectively, with no statistically significant difference between patients on inotropes for !15 days. Two-year mortality was 66% in the RVAD cohort. Cohorts with prolonged inotropic support ($15 days) or RVAD implantation had significantly higher two-year mortality, 53% vs. 21% in the #14 days of inotrope cohort, p ! 0.0001 (Figure 1). There was also an increased incidence of the combined end-point in this group (Figure 2). Conclusion: In patients with continuous-flow LVADs, days of inotropes are only significantly associated with mortality if required beyond 14 days. RVAD implantation and prolonged inotropic support are associated with a 2.5 fold increase in mortality. Defining these patients as severe RV failure versus non-severe RV failure yields a clinically significant outcome. Stratification of RV failure based on inotrope support for 0-7 or 8-14 days is not associated with long term clinical outcomes and appears unnecessary.
Background: Left Ventricular Assist Device (LVAD) pump thrombosis (PT) is a devastating complication of mechanical circulatory support. The diagnosis of LVAD thrombus is difficult in vivo, often only suggested by markers of hemolysis and echocardiographic features, which lack sensitivity. We sought to test a probe with high avidity anti-fibrin 99mTc to localize and quantify thrombus within the high shear environment of titanium axial-flow pumps. Methods: Monomeric bifunctional ligands with a fibrin-specific peptide, a short spacer, and technetium chelating amino acid sequence (F1A) were covalently inter-coupled via a 4-arm-PEG2000 tetramer to form F4A. Each was radiolabeled with 99mTc using the IsoLink procedure. We collected 20 explanted HeartMate II LVADs, of which 9 were explanted for suspected pump thrombosis and 11 were explanted during heart transplant or exchange for other complications. Ex-vivo imaging of explanted pumps was conducted in plasma using a mock circulatory loop running at 9400 RPM for 30 minutes as has previously been described. After imaging the devices were sent to the manufacturer for disassembly and thorough inspection for thrombus. Results: The majority of patients were male (85%) with a mean age of 54.1 6 9.8 and a median INTERMACS profile of 2. The median time of LVAD support prior to explant was 7.6 6 7.2 months. Of the 9 patients exchanged for suspected pump thrombosis all had undetectable haptoglobin levels and mean LDH levels of 3520 6 2596. All 9 had CT scans prior to LVAD exchange without any visualized thrombus or kinking of the inflow or outflow cannulas. Two of the pumps have been disassembled and inspected by the manufacturer. Both pumps were in patients with suspected pump thrombosis and both the pumps had thrombus found on SPECT imaging and on visual inspection (Figure 1A and 1B). Conclusions: A novel, fibrin-specific 99mTc small tetrameric probe offers the potential to detect, localize, and quantify intra-LVAD thrombus noninvasively. Once verified in a large cohort this agent offers the opportunity to diagnose LVAD pump thrombosis at an earlier stage. Definite and early diagnosis may confer therapeutic options to avoid pump failure and/or costly and morbid LVAD exchange.
Figure 1.
Figure 2.
233 Impact of Cytomegalovirus on Survival After Heart Transplant: analysis of 20,000 Patients from the UNOS Registry Data Guha Ashrith, Ahmed Daoud, Larry D. Teeter, Javier Amione-Guerra, Andrea M. Cordero-Reyes, Edward Gravis, Barry H. Trachtenberg, Arvind Bhimaraj, Osama A. Gaber, Scott Scheinin, Guillermo Torre-Amione, Jerry D. Estep; The Methodist Hospital, Houston, TX
Figure 1.
Background: Cytomegalovirus (CMV) infection has been implicated in a number of complications after heart transplant. Our study aim was to determine the effects of CMV donor-recipient status in a large cohort of patients undergoing heart