- Email: [email protected]
Difficulty in Dying on LVAD: A Preliminary Analysis of Factors Associated with Time to LVAD Withdrawal
S438
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
interfered with satisfaction with sexual function. These findings highlight the importance of assessing multiple indicators of physical health and may provide direction for physical health focused therapies after CF-LVAD implantation.
Results: From June 2017 to August 2018, 271 PROMIS scores were completed from 132 different LVAD patients (55 § 11 years old; 81% male; 58% BTT). Time since LVAD implantation ranged from 32 days to over 8 years (median 945 days). Compared to the general population, LVAD patients reported worse functional status but similar levels of pain and depression (Figure 1). KCCQ-12 was captured for 73 different patients and demonstrated significant positive correlation between the instruments (0.713, p < 0.0001) (Figure 2). Conclusion: The PROMIS score shows a good correlation with the KCCQ12 in LVAD patients. Further study is needed to determine its utility in predicting outcomes.
1108 PROMISing New Tool Correlates Well with Kansas City Cardiomyopathy Questionnaire in Left Ventricular Assist Device Patients B.C. Ayers, K. Wood, E. Lee, J. Bruckel, F. Ling, V. Kutyifa, S. McNitt, H. Vidula, J. Alexis, S. Prasad and I. Gosev. University of Rochester, Rochester, NY. Purpose: Patient-Reported Outcomes Measurement Information System (PROMIS) is a computerized assessment that has been validated across multiple disciplines and chronic disease states. There is limited use of PROMIS in the heart failure patient population. We describe PROMIS scores in a large LVAD patient cohort and compare functional domain measurement to the Kansas City Cardiomyopathy Questionnaire (KCCQ12). Methods: LVAD patients completed the PROMIS computer adaptive test for physical function, pain and depression in addition to the KCCQ-12 survey at outpatient visits. PROMIS instruments are standardized to a mean score of 50 for the general population. Only KCCQ-12 completed within 90 days of a PROMIS score were included in the analysis. The nonparametric Spearman’s rank correlation measure was used to estimate the strength of the relationship between the PROMIS function score and the KCCQ-12 measure.
1109 Difficulty in Dying on LVAD: A Preliminary Analysis of Factors Associated with Time to LVAD Withdrawal S. Nakagawa,1 M. Ando,2 K. Takeda,1 A. Rosen,1 H. Takayama,1 A.R. Garan,1 V.K. Topkara,1 M. Yuzefpolskaya,1 P.C. Colombo,1 Y. Naka,1 and C.D. Blinderman.1 1Columbia University Medical Center, New York, NY; and the 2Tokyo University, Tokyo, Japan. Purpose: When left ventricular assist device (LVAD) therapy no longer fullfills a patient’s desired quality of life, the patient or their surrogate may request withdrawal. However, the details of LVAD withdrawal have not been previously studied. The aim of this study is to describe the factors associated with LVAD withdrawal. Methods: Among newly implanted LVADs from 2010 until July 2018 in a single institution, those who underwent withdrawal were included. We divided this cohort into 2 groups based on whether patients initiated the decision of withdrawal (PT+) or patients could not participate due to lack of decision-making capacity (PT-). In PT+, we calculated the days between the patients’ request of withdrawal and deactivation (WD_PT+). In PT-, we calculated the days between the time when patients lost capacity and deactivation (WD_PT-). Multivariate linear
Abstracts
S439
regression analyses were done to predict WD_PT-. Place of withdrawal, palliative care involvement, and other clinical factors were also analyzed. Results: A total of 61 patients (14 in PT+, 47 in PT-) underwent LVAD withdrawal. Mean age at death was 65.4 §10.1years and 85.2% were male. Median survival was 170 days. Palliative care was involved in the majority of LVAD withdrawals. Most LVAD withdrawals occurred in the ICU. The median WD_PT was 5.5 days (IQR 39.1), and was shorter in the ICU (n=9, 1 day, IQR 7) than non-ICU settings (n=5, 46 days, IQR 95.5). The median WD_PT- was 5.5 days (IQR 9.3), and was shorter in the ICU (n=42, 4 days, IQR 10) than in non-ICU settings (n=4, 13 days, IQR 32.3). A multivariate analysis showed that male and ICU setting were significantly associated with WD_PT- (p=0.025 for male, p=0.005 for ICU setting) Conclusion: The majority of LVAD withdrawals were done in the ICU. Patients’ request of withdrawal was respected sooner and surrogates’ decisions for withdrawal occurred sooner in the ICU. Time to surrogates’ decision for withdrawal was shorter in male patients. Palliative care was involved in the majority of withdrawals.
PT+ (n=14) Age, mean (§ SD) Male, n (%) DT, n (%) Caregiver Spouse, n (%) Palliative care consult, n (%) Death in the ICU, n (%) Death in hospice, n (%) Mechanical ventilation in the last week, n (%) Renal Replacement therapy in the last week, n (%) Cause of death, n (%) Multi-system Organ failure Stroke Clinical trajectory, n (%) Early (death within 90 days after LVAD implantation) Acute (Derived QOL once, but developed an unexpected acute event and died within 14 days) Survival days, median (IQR) WD_PT+, median (IQR) WD_PT-, medican (IQR)
PT-(n=47)
68.1 § 10.4 14 (100) 10 (71.4) 9 (64.3) 13 (92.8) 9 (64.3) 2 (14.3) 4 (28.6)
64.8 § 10.0 38 (80.9) 30 (63.8) 26 (55.3) 28 (59.6) 42 (89.4) 3 (6.4) 37 (78.7)
2 (14.3)
21 (44.7)
5 (35.7) 0 (0)
13 (27.7) 21 (44.6)
3 (21.4)
16 (34.8)
0 (0)
16 (34.8)
239 (1218) 5.5 (39.1) NA
139.5 (791.8) NA 5.5 (9.3)
1110 Younger Patients Have Poorer Social Functioning Than Older Patients after LVAD Placement R.O. HoffmanIII1 K.E. Sandau,2 C.S. Lee,3 S.P. Jaganathan,1 P. Mudigonda,1 P. Eckman,4 R. Gaberich,5 C. Weaver,4 S. Joseph,6 S. Hall,6 S. Carey,6 J. Cowger,7 S. Chaudry,8 S.E. Schroeder,9 G. Conway,1 E.Y. Barati,10 M. Soni,10 J. Marble,11 K.M. Faulkner,3 and D.S. Feldman.1 1Cardiology, University of Cincinnati College of Medicine, Cincinnati, OH; 2Bethel University, Arden Hills, MN; 3Boston College Connell School of Nursing, Chestnut Hill, MA; 4Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN; 5Minneapolis Heart Institute Foundation, Minneapolis, MN; 6Baylor University Medical Center, Dallas, TX; 7Henry Ford, Detroit, MI; 8St. Vincent Center, Indianapolis, IN; 9Bryan Heart Center, Lincoln, NE; 10University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; and the 11 University of Pennsylvania, Philadelphia, PA. Purpose: Left ventricular assist devices (LVADs) are increasingly common, approximating 2,500 implants a year. The average age at implant in the modern era is 52 years. Data from more than 15,000 patients
participating in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database demonstrate improved quality of life (QOL) after LVAD implant and through 24 months. However, there is a paucity of data in evaluating how patients who are older vs. younger contend with the social impact of living with a LVAD. Challenges may include addressing the impact of an LVAD on social interactions, employment, finances, self-image and intimacy based on the patient’s age. Methods: A multi-site prospective, descriptive study evaluated QOL using the QOLVAD questionnaire. We report preliminary findings for Social Domain scores (possible range 0-100 with a higher scores suggesting better functioning). Two-sample T-tests were used to compare social wellbeing for younger (n=68) vs. older patients (n=118). Results: The overall sample (n=186) was 58.5§13.8 years old, 82.7% were male, 77.3% were white, 50% were bridge to transplant, 30% destination therapy. Surveys were completed at median time (25th, 75th percentile) of 44 weeks (17.5, 115.5) post-VAD. The average social domain score (n = 185) was 73.4§16.7. Patients 55 and younger had a mean social domain score of 68.8§17.5, which was significantly higher than patients age 56 and older who had a mean score of 76.0§15.7 (p=0.006). Conclusions: The findings suggest younger patients struggle more socially than older patients do after LVAD implant. Future interventions may consider class topics such as how to re-enter the work force, including work with local agencies focused on vocational rehabilitation after LVAD placement. Patient education and support groups for younger patients could include topics of intimacy and sexuality particularly for younger patients. Innovative support could include collaborating with clothing industries to design garments that support and improve self-image. Future research on the impact and success of such interventions could be measured using the QoLVAD tool.
1111 Continuous Flow Left Ventricular Assist Devices Can Improve Sleep Quality of Advanced Heart Failure Patients K. Nakamoto,1 T. Ohtani,1 F. Sera,1 Y. Tsukamoto,1 K. Toda,2 S. Hikoso,1 Y. Sawa,2 and Y. Sakata.1 1Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan; and the 2 Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan. Purpose: Sleep disturbance deteriorates quality of life, and sleep quality of heart failure (HF) patients is worse than that of non-HF patients. In patients with advanced HF, continuous left ventricular assist device (cfLVAD) is used for the improvement of their quality of life and prognosis. However, the effect on sleep quality of cf-LVAD therapy is unknown. Therefore, this study was aimed to reveal the effect of cf-LVAD on sleep quality. Methods: Thirteen patients who received polysomnography before and after cf-LVAD implantation in Osaka University Hospital were studied. Patient characteristics and sleep parameters, including total sleep time, sleep efficiency (total sleep time/sleep period time), sleep latency, wake time after sleep onset, and the proportion of slow wave sleep to total sleep time, were obtained. Results: After LVAD implantation, BNP levels decreased (399§110 to 163§144 pg/ml, P<0.05), and estimated GFR increased (56§17 to 76§12 ml/min/m2, P<0.001). Total sleep time became longer and sleep efficiency improved (Table). Sleep latency and wake time after sleep onset became shorter after cf-LVAD implantation. Slow wave sleep proportion tended to increase after cf-LVAD implantation. These data indicated the improvement of sleep quality. On the other hand, apnea hypopnea index (AHI) was not improved after cf-LVAD implantation. Conclusion: Cf-LVAD therapy improves sleep quality in advanced heart failure patients.
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
interfered with satisfaction with sexual function. These findings highlight the importance of assessing multiple indicators of physical health and may provide direction for physical health focused therapies after CF-LVAD implantation.
Results: From June 2017 to August 2018, 271 PROMIS scores were completed from 132 different LVAD patients (55 § 11 years old; 81% male; 58% BTT). Time since LVAD implantation ranged from 32 days to over 8 years (median 945 days). Compared to the general population, LVAD patients reported worse functional status but similar levels of pain and depression (Figure 1). KCCQ-12 was captured for 73 different patients and demonstrated significant positive correlation between the instruments (0.713, p < 0.0001) (Figure 2). Conclusion: The PROMIS score shows a good correlation with the KCCQ12 in LVAD patients. Further study is needed to determine its utility in predicting outcomes.
1108 PROMISing New Tool Correlates Well with Kansas City Cardiomyopathy Questionnaire in Left Ventricular Assist Device Patients B.C. Ayers, K. Wood, E. Lee, J. Bruckel, F. Ling, V. Kutyifa, S. McNitt, H. Vidula, J. Alexis, S. Prasad and I. Gosev. University of Rochester, Rochester, NY. Purpose: Patient-Reported Outcomes Measurement Information System (PROMIS) is a computerized assessment that has been validated across multiple disciplines and chronic disease states. There is limited use of PROMIS in the heart failure patient population. We describe PROMIS scores in a large LVAD patient cohort and compare functional domain measurement to the Kansas City Cardiomyopathy Questionnaire (KCCQ12). Methods: LVAD patients completed the PROMIS computer adaptive test for physical function, pain and depression in addition to the KCCQ-12 survey at outpatient visits. PROMIS instruments are standardized to a mean score of 50 for the general population. Only KCCQ-12 completed within 90 days of a PROMIS score were included in the analysis. The nonparametric Spearman’s rank correlation measure was used to estimate the strength of the relationship between the PROMIS function score and the KCCQ-12 measure.
1109 Difficulty in Dying on LVAD: A Preliminary Analysis of Factors Associated with Time to LVAD Withdrawal S. Nakagawa,1 M. Ando,2 K. Takeda,1 A. Rosen,1 H. Takayama,1 A.R. Garan,1 V.K. Topkara,1 M. Yuzefpolskaya,1 P.C. Colombo,1 Y. Naka,1 and C.D. Blinderman.1 1Columbia University Medical Center, New York, NY; and the 2Tokyo University, Tokyo, Japan. Purpose: When left ventricular assist device (LVAD) therapy no longer fullfills a patient’s desired quality of life, the patient or their surrogate may request withdrawal. However, the details of LVAD withdrawal have not been previously studied. The aim of this study is to describe the factors associated with LVAD withdrawal. Methods: Among newly implanted LVADs from 2010 until July 2018 in a single institution, those who underwent withdrawal were included. We divided this cohort into 2 groups based on whether patients initiated the decision of withdrawal (PT+) or patients could not participate due to lack of decision-making capacity (PT-). In PT+, we calculated the days between the patients’ request of withdrawal and deactivation (WD_PT+). In PT-, we calculated the days between the time when patients lost capacity and deactivation (WD_PT-). Multivariate linear
Abstracts
S439
regression analyses were done to predict WD_PT-. Place of withdrawal, palliative care involvement, and other clinical factors were also analyzed. Results: A total of 61 patients (14 in PT+, 47 in PT-) underwent LVAD withdrawal. Mean age at death was 65.4 §10.1years and 85.2% were male. Median survival was 170 days. Palliative care was involved in the majority of LVAD withdrawals. Most LVAD withdrawals occurred in the ICU. The median WD_PT was 5.5 days (IQR 39.1), and was shorter in the ICU (n=9, 1 day, IQR 7) than non-ICU settings (n=5, 46 days, IQR 95.5). The median WD_PT- was 5.5 days (IQR 9.3), and was shorter in the ICU (n=42, 4 days, IQR 10) than in non-ICU settings (n=4, 13 days, IQR 32.3). A multivariate analysis showed that male and ICU setting were significantly associated with WD_PT- (p=0.025 for male, p=0.005 for ICU setting) Conclusion: The majority of LVAD withdrawals were done in the ICU. Patients’ request of withdrawal was respected sooner and surrogates’ decisions for withdrawal occurred sooner in the ICU. Time to surrogates’ decision for withdrawal was shorter in male patients. Palliative care was involved in the majority of withdrawals.
PT+ (n=14) Age, mean (§ SD) Male, n (%) DT, n (%) Caregiver Spouse, n (%) Palliative care consult, n (%) Death in the ICU, n (%) Death in hospice, n (%) Mechanical ventilation in the last week, n (%) Renal Replacement therapy in the last week, n (%) Cause of death, n (%) Multi-system Organ failure Stroke Clinical trajectory, n (%) Early (death within 90 days after LVAD implantation) Acute (Derived QOL once, but developed an unexpected acute event and died within 14 days) Survival days, median (IQR) WD_PT+, median (IQR) WD_PT-, medican (IQR)
PT-(n=47)
68.1 § 10.4 14 (100) 10 (71.4) 9 (64.3) 13 (92.8) 9 (64.3) 2 (14.3) 4 (28.6)
64.8 § 10.0 38 (80.9) 30 (63.8) 26 (55.3) 28 (59.6) 42 (89.4) 3 (6.4) 37 (78.7)
2 (14.3)
21 (44.7)
5 (35.7) 0 (0)
13 (27.7) 21 (44.6)
3 (21.4)
16 (34.8)
0 (0)
16 (34.8)
239 (1218) 5.5 (39.1) NA
139.5 (791.8) NA 5.5 (9.3)
1110 Younger Patients Have Poorer Social Functioning Than Older Patients after LVAD Placement R.O. HoffmanIII1 K.E. Sandau,2 C.S. Lee,3 S.P. Jaganathan,1 P. Mudigonda,1 P. Eckman,4 R. Gaberich,5 C. Weaver,4 S. Joseph,6 S. Hall,6 S. Carey,6 J. Cowger,7 S. Chaudry,8 S.E. Schroeder,9 G. Conway,1 E.Y. Barati,10 M. Soni,10 J. Marble,11 K.M. Faulkner,3 and D.S. Feldman.1 1Cardiology, University of Cincinnati College of Medicine, Cincinnati, OH; 2Bethel University, Arden Hills, MN; 3Boston College Connell School of Nursing, Chestnut Hill, MA; 4Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN; 5Minneapolis Heart Institute Foundation, Minneapolis, MN; 6Baylor University Medical Center, Dallas, TX; 7Henry Ford, Detroit, MI; 8St. Vincent Center, Indianapolis, IN; 9Bryan Heart Center, Lincoln, NE; 10University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; and the 11 University of Pennsylvania, Philadelphia, PA. Purpose: Left ventricular assist devices (LVADs) are increasingly common, approximating 2,500 implants a year. The average age at implant in the modern era is 52 years. Data from more than 15,000 patients
participating in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database demonstrate improved quality of life (QOL) after LVAD implant and through 24 months. However, there is a paucity of data in evaluating how patients who are older vs. younger contend with the social impact of living with a LVAD. Challenges may include addressing the impact of an LVAD on social interactions, employment, finances, self-image and intimacy based on the patient’s age. Methods: A multi-site prospective, descriptive study evaluated QOL using the QOLVAD questionnaire. We report preliminary findings for Social Domain scores (possible range 0-100 with a higher scores suggesting better functioning). Two-sample T-tests were used to compare social wellbeing for younger (n=68) vs. older patients (n=118). Results: The overall sample (n=186) was 58.5§13.8 years old, 82.7% were male, 77.3% were white, 50% were bridge to transplant, 30% destination therapy. Surveys were completed at median time (25th, 75th percentile) of 44 weeks (17.5, 115.5) post-VAD. The average social domain score (n = 185) was 73.4§16.7. Patients 55 and younger had a mean social domain score of 68.8§17.5, which was significantly higher than patients age 56 and older who had a mean score of 76.0§15.7 (p=0.006). Conclusions: The findings suggest younger patients struggle more socially than older patients do after LVAD implant. Future interventions may consider class topics such as how to re-enter the work force, including work with local agencies focused on vocational rehabilitation after LVAD placement. Patient education and support groups for younger patients could include topics of intimacy and sexuality particularly for younger patients. Innovative support could include collaborating with clothing industries to design garments that support and improve self-image. Future research on the impact and success of such interventions could be measured using the QoLVAD tool.
1111 Continuous Flow Left Ventricular Assist Devices Can Improve Sleep Quality of Advanced Heart Failure Patients K. Nakamoto,1 T. Ohtani,1 F. Sera,1 Y. Tsukamoto,1 K. Toda,2 S. Hikoso,1 Y. Sawa,2 and Y. Sakata.1 1Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan; and the 2 Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan. Purpose: Sleep disturbance deteriorates quality of life, and sleep quality of heart failure (HF) patients is worse than that of non-HF patients. In patients with advanced HF, continuous left ventricular assist device (cfLVAD) is used for the improvement of their quality of life and prognosis. However, the effect on sleep quality of cf-LVAD therapy is unknown. Therefore, this study was aimed to reveal the effect of cf-LVAD on sleep quality. Methods: Thirteen patients who received polysomnography before and after cf-LVAD implantation in Osaka University Hospital were studied. Patient characteristics and sleep parameters, including total sleep time, sleep efficiency (total sleep time/sleep period time), sleep latency, wake time after sleep onset, and the proportion of slow wave sleep to total sleep time, were obtained. Results: After LVAD implantation, BNP levels decreased (399§110 to 163§144 pg/ml, P<0.05), and estimated GFR increased (56§17 to 76§12 ml/min/m2, P<0.001). Total sleep time became longer and sleep efficiency improved (Table). Sleep latency and wake time after sleep onset became shorter after cf-LVAD implantation. Slow wave sleep proportion tended to increase after cf-LVAD implantation. These data indicated the improvement of sleep quality. On the other hand, apnea hypopnea index (AHI) was not improved after cf-LVAD implantation. Conclusion: Cf-LVAD therapy improves sleep quality in advanced heart failure patients.