Cognitive Improvement Post-Placement of Left Ventricular Assist Device

The 20th Annual Scientific Meeting

316 The Prognostic Implications of Changes in Albumin Following LVAD Implantation Dipika J. Gopal, Thomas Hanff, Jeremy Mazurek, Edward Grandin, Jessica Howard, Rhondalyn Ford-McLean, Joyce Wald, Michael Acker, Lee Goldberg, Pavan Atluri, Kenneth Margulies, J. Eduardo Rame, Edo Y. Birati; University of Pennsylvania, Philadelphia, PA

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HFSA

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Purpose: Rotational thromboelastometry (ROTEM), a method for hemostasis testing in whole blood, has been used to manage and adjust anti-coagulation therapy in post VAD implant patients. Performing ROTEM prior to implant may shed light on important hemostatic characteristics in patients that develop pump thrombosis (PT) post VAD implantation. Methods: All VAD implantations at our institution between 2008 through 2015 were included in the analysis. Suspected PT was defined as a pump-related malfunction and hemolysis and definitive PT required visualized thrombus at the time of explant. A subset of patients underwent ROTEM prior to postimplant. The patients’ EXTEM CT (latency time of clot formation once start reagent has been added to a patient’s blood) was measured and analyzed. Results: 139 patients were implanted during the study time (21% female). 28 patients had suspected or definitive pump thrombosis (25%). There were no significant differences found in mean age, gender, etiology of heart failure, or medications (see Table 1). Patients with PT were more likely to have public insurance (P = .03). There was no significant difference in patients’ pre-implant EXTEM CT between non-PT and PT (mean 56 and 62, respectively, P = .10). Using Friedman’s ANOVA, the ROTEM EXTEM CT value increased over the pre-implant through 3 month post-implant interval (P = .006, n = 15). This was not looked at separately for patients who experienced a thrombotic event vs patients who did not due to low sample size. Conclusion: Other than insurance type, there are no easily identifiable clinical or pre-implant risk factors associated with PT. Furthermore, there was no significant difference preimplant ROTEM EXTEM CT between the two groups. It is notable that there is a significant increase of patients’ CT over the 3 month interval, regardless of a diagnosis of thrombosis. Further studies are needed to explore the alterations in hemostatics in VAD patients who experience PT.

Mechanical assist devices have emerged as an established therapeutic option for patients with end-stage heart failure. Recognizing patients who will do poorly postimplant is essential to optimize patient management and outcomes. Hypothesis: Since albumin level may reflect nutritional status, improvement in albumin from pre to postimplant may be an important prognostic indicator in patients treated with continuous flow left ventricular assist devices (cfLVAD). Methods: In this retrospective single center study we included all patients who underwent cfLVAD implantation (HeartMate II and HeartWare HVAD) at an academic center from 2008 to 2014. We excluded patients who died, were transplanted, or hospitalized during the first 3 months post-implant. Pre-implant albumin was defined as the albumin closest to but prior to the day of implant and not more than 30 days before surgery. Hypoalbuminemia was defined as <3.5 g/dL and normal albumin as ≥3.5 g/dL. We tested for association with clinical outcomes post cfLVAD including 1 and 2-year survival and time to first post-implant hospitalization. Results: From 202 total patients (80% male, mean age 56 ± 16 years), 145 were included for survival analysis and 93 were included for hospitalization analysis. The mean albumin at pre-implant, 3-months post-implant and 6-months post-implant was 3.5 ± 0.6 g/ dL, 3.6 ± 0.7 g/dL, and 3.9 ± 0.5 g/dL, respectively (P < .01). Hypoalbuminemia at 3-months post-implant correlated with increased mortality (HR 2.19 CI 1.20–4.01, P = .01) and reduced time to first post-implant hospital admission (HR 2.36 CI 1.37–4.06, P < .01). Decrease in albumin from pre-implant to 3-months post-implant was also associated with increased mortality (HR 2.93 CI 1.57–5.44, P < .01) and shorter time to first postimplant hospital admission (HR 1.70 CI 1.03–2.81, P = .04). Subgroup analysis revealed that those who started with hypoalbuminemia but had normal albumin values at 3-months post-implant had improved survival and longer time to first post-implant hospitalization than those who had persistent hypoalbuminemia, decrease in albumin over time and even those who maintained normal albumin throughout. Conclusions: Our study is the first to demonstrate the importance of post-implant albumin as well as the changes in albumin from pre- to post-implant on the prognosis of cfLVAD patients. This suggests that regardless of pre-implant albumin, therapeutic intervention to improve albumin or nutritional status post-implant may prevent hospitalizations and improve outcomes.

318 Cognitive Improvement Post-Placement of Left Ventricular Assist Device Mark R. Bonnell, Drake Steed, Thomas Schwann, George Moukarbel, Samer Khoury, Michelle Hudson, Allison Meyers-Fabian, Mary Haines; University of Toledo Medical Center, Toledo, OH

317 Clinical and Hemostatic Characteristics of Patients With Ventricular Assist Device Thrombosis Kristina Quinn1, Demetrios Doukas1, Neelam Balasubramanian1, Tania Torres2, Jeanine Walenga1, Erin Coglianese1; 1Loyola University Medical Center, Maywood, IL; 2Loyola University Stritch School of Medicine, Maywood, IL

Background: Either as bridge to transplant or destination therapy, left ventricular assist devices (LVADs) serve many patients with advanced heart failure (AHF). Systemic dysfunction, including extended periods of cerebral hypoperfusion, places patients with AHF at increased risk for cognitive decline. Despite reports of improvement in multiple body systems following LVAD placement, including increased cerebral perfusion, research examining longitudinal outcomes of cognition is sparse. In prior research (n = 12),

S110 Journal of Cardiac Failure Vol. 22 No. 8S August 2016 we found improvements in verbal memory 6 months and 12 months post-placement and in visual memory between 12 and 24 months. Objectives: The purpose of the current follow-up study was to assess the impact of an increased sample (n = 17) and additional follow-up testing. Methods: We again compared cognition pre- and postLVAD placement across time points (A: 3–6 months; B: 6–12 months; C: 2 years) for individuals using paired samples t-tests. Individuals were administered the Repeatable Battery for the Assessment of Neuropsychological Status and the Trail Making Test. Patients’ cognition was stable or improved up to 24 months post-placement. Results: In addition to the verbal and visual memory impairment previously observed, we now saw. Statistically significant improvement in cognition was observed on measures assessing processing speed (Pre to A) and verbal recognition memory (Pre to B). Trends toward significance were observed in visual memory (Pre to A), delayed list memory (Pre to B), and delayed story memory (A to C). Conclusions: Findings add to limited extant research showing stable or modest improvements in cognition and provide further understanding of the effects of LVAD placement on neurocognition.

319 The Impact of Hemolysis on Outcomes of Cardiogenic Shock Patients Supported With Impella Percutaneous Left Ventricular Assist Device Christopher M. Bianco1, Ashley E. Burch2, George Mawardi1, Kevin Michael Lamm1, Hassan Alhosaini1; 1Brody School of Medicine at East Carolina University, Greenville, NC; 2East Carolina University, Greenville, NC

implantation. Methods: A single center retrospective review of all patients implanted with a LVAD between January, 2010 and September, 2015. Obesity was defined as BMI ≥ 30 kg/m2. The study population was stratified based on BMI. Results: 275 patients underwent LVAD implantation, of whom 108 (39%) were obese. Mean BMI was 34.8 ± 4.1 and 24.4 ± 3.1 kg/m2 in obese and non-obese groups, respectively. There was no significant difference in mean days on LVAD support (514.9 ± 470.7 obese vs 507.8 ± 465.4 non-obese, P = .9). Compared to non-obese patients, those in the obese group were younger (52.1 ± 11.4 vs 58.0 ± 13.7 years, P < .01), more likely to be African-American (73.1% vs 53.3%, P < .01), and have a non-ischemic etiology as the cause of heart failure (70.4% vs 56.9%, P = .02). They were also more likely to suffer from diabetes (51.9% vs 31.7%, P < .01) and OSA (26.9% vs 7.2%, P < .01). There were no significant differences between the 2 groups in the pre-op INTERMACS profiles, implant strategy at time of LVAD (BTT: 56.5% vs 48.5%, P = .2), type of LVAD (axial vs centrifugal), kidney/liver function. During the index hospitalization for LVAD implant, there were no significant differences between the 2 groups in the days on vasopressors (6.4 ± 6.4 vs 6.0 ± 6.7, P = .58) and on inotropic therapy (11.9 ± 9.3 vs 11.1 ± 11.9, P = .54). Importantly, the obese and non-obese groups had similar lengths of stay for index LVAD surgery (30.3 ± 21.7 vs 28.1 ± 20.4, P = .39) and similar rates of 30 day re-hospitalization (27% vs 26%, P = .84). Furthermore, the 1 year survival (Fig. 1) did not differ between the 2 groups (82.4% obese vs 75.5% nonobese, P = .21). Conclusion: In this single center experience, obesity does not appear to adversely impact length of stay, 30-day re-hospitalization, or 1 year survival after LVAD implantation. Whether more severe forms of obesity affect clinical outcomes deserve further study.

Introduction: Impella use in cardiogenic shock has been shown to improve hemodynamic parameters and markers of end organ function. The incidence of hemolysis in patients undergoing Impella support has varied widely in the literature ranging from 7.5 to 62.5%. Furthermore it is largely unknown whether hemolysis complicating Impella support has an impact on clinical course and prognosis. Methods: We performed retrospective analysis of sixty-nine consecutive patients who underwent Impella placement for cardiogenic shock from Jan 1, 2012 to December 31, 2015 at a large academic medical center. Results: Patients were 67% males, 62% Caucasians, and 87% presented with AMI. The incidence of hemolysis complicating Impella support was 29% (n = 20). Hemolysis was not associated with increased rates of AKI (80% vs 73.5%, P = .56), nor the need for renal replacement therapy (35% vs 16.3%, P = .10). Hemolysis was associated with a significantly longer ICU length of stay (LOS) (mean 13.5 days vs 7.0 days, P = .004) and total hospital LOS (mean 18.5 days vs 10.9 days, P = .01). Approaching statistical significance (P = .07), patients with hemolysis were 2.69 times more likely to require a transfusion than patients without hemolysis. Hemolysis was not associated with increased mortality at 6 months (60% vs 55%, P = .55). Conclusions: Hemolysis is a common complication of Impella support in cardiogenic shock, but is not associated with increased incidence of AKI or RRT. Hemolysis does not impact mortality at 6 months. Hemolysis is associated with prolonged ICU and total hospital LOS.

321 Frailty is Highly Prevalent in Patients Being Considered for a Left Ventricular Assist Device and is Associated With Depression and Reduced Quality of Life Gordon R. Reeves 1 , Omar G. Jimenez 2 , Evelyn M. Horn 3 , Sean Pinney 4 , Deena Goldwater 4 , Alex Reyentovich 5 , Victoria Dickson 6 , Sergio Teruya 7 , Julissa Alvarez1, Suchit Bhutani1, Mathew S. Maurer7; 1Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA; 2Columbia University Medical Center, New York, NY; 3Weill Cornell NYPH, New York, NY; 4Mount Sinai Hospital, New York, NY; 5New York University School of Medicine, New York, NY; 6NYU Langone Medical Center, New York, NY; 7Columbia University Medical Center, New York, NY

320 Obesity Does Not Impact 1 Year Survival After LVAD Implantation Farooq H. Sheikh, David T. Majure, Sara Ahmed, Maria E. Rodrigo, Sandeep M. Jani, Mark Hofmeyer, Steven W. Boyce, Samer S. Najjar; MedStar Washington Hospital Center, Washington, DC Purpose: The obesity paradox is well described in patients with heart failure. Among those who undergo heart transplantation, morbid obesity has been shown to adversely impact survival. We sought to determine the effect of obesity on survival after LVAD

Introduction: Frailty reflects a state of decreased physiological reserve associated with a relative risk >2 for mortality and morbidity. The Fried frailty phenotype is the most widely adopted frailty definition. However, the prevalence of the frailty phenotype and the factors associated with it have not been systematically studied in patients with advanced HF. Hypothesis: Frailty will be present in a majority of patients with advanced HF and will be associated with older age and comorbidity burden. Methods: We assessed the Fried frailty phenotype in 69 advanced HF patients considered for an LVAD as part of a prospective, multicenter study. Frailty was defined by the presence of ≥3 of the Fried criteria: slow gait speed, low handgrip strength, inactivity, exhaustion and weight loss, assessed using standardized protocols. Differences in clinical characteristics between frail and not frail subjects were evaluated using Welch’s t-test. Results: Participant age was 63.1 ± 11.4 years, 78% were male, and INTERMACS profile was 2.9 ± 1.0; 61 received an LVAD (67% as destination therapy). Frailty was prevalent in 78% (n = 54) of participants. Differences by frailty status are shown below. Conclusions: The Fried frailty phenotype is highly prevalent among older adults being considered for an LVAD and is associated with reduced QOL and depression. Albumin, which has been used as a marker of frailty in patients in other types of advanced heart disease, was lower in frail advanced HF patients. Age and comorbidities were not significantly different between