Functional Outcomes of Left Ventricular Assist Device Patients Receiving Inpatient Rehabilitation

Abstracts S337 of depression of orthotropic heart transplantation (OHT) recipients on outcomes such as survival, hospitalization, infection and transplant rejection, medication and outpatient appointment and compliance. Methods: In this retrospective study, we included 43 patients with pre OHT and post psychosocial evaluation performed by a social worker. Patients were stratified by the presence or absence of depression on index encounter. Clinical data and information regarding the examined outcomes were extracted from medical records. Pearson correlation coefficients were used on continuous variables, while independent t tests and χ ² tests of independence were used to compare groups for continuous and discrete dependent variables respectively. Relative risk and descriptive data were obtained through cross tabs and descriptive analyses. Results: Patients with depression had higher mean first year hospitalizations (4.7±3.1 vs. 2.2±1.9, p =  0.046), higher overall hospitalization rates (8.3±4.4 vs. 4.6±4.2, p =  0.025) and higher rates of admission for infections (2.8±1.3 vs. 1.5±1.4, p = 0.018.) (Table 1.). Moreover, depressed recipients were more likely to be non-compliant with medications (RR =  3.5, 95% CI (1.2, 10.2), p= 0.046). There was no significant difference in total rejections, outpatient appointments compliance and survival. Conclusion: Depression is a strong predictor of poor medication compliance and higher rates of hospitalization of transplant recipients. Further prospective studies are warranted to confirm these findings, with focus on interventions to improve post-transplant adherence and complications in depressed recipients.

Clinical Outcomes in Transplant Recipients with and without Depression

FIRST YEAR HOSPITALIZATIONS OVERALL HOSPITALIZATIONS INFECTIONS

DEPRESSED PATIENTS (N= 9)

NON-DEPRESSED PATIENTS (N= 34) P

4.7±3.1 8.3±4.4 2.8±1.3

2.2±1.9 4.6±4.2 1.5±1.4

0.046 0.025 0.018

9( 39) Development and Validation of Patient-Centered Knowledge Scale for LVAD Placement K.M. Kostick ,1 C. Minard,2 E. Delgado,1 L. Wilhelms,1 C. Bruce,1 J.D. Estep,3 M. Loebe,3 R. Volk,4 J.S. Blumenthal-Barby.1  1Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX; 2Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX; 3DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX; 4Health Services Research, The University of Texas M.D. Anderson Cancer Center, Houston, TX. Purpose: Incorporating patient values and beliefs into shared medical decision-making is a central tenet of patient-centered, culturally-competent healthcare advocated by the Institute of Medicine and the American Medical Association. Achievement of this goal is currently constrained by a lack of operationalized methodologies for measuring patient knowledge and values. This paper presents the results of a replicable methodology for developing a culturally-informed and patient-centered measure of knowledge about Left Ventricular Assist Device (LVAD) therapy. The LVAD Knowledge Scale was designed to facilitate discussion and measure of candidate understanding of treatment options, two key components of the informed consent process. Methods: Using structured interviews and free-listing techniques (n= 45), we identified top patient values and decisional needs, and provider’s perspectives on essential knowledge needs for informed consent. From this list, we generated 20 Knowledge Scale question items that were further refined in cognitive interviews with patient consultants. A finalized 20-item LVAD Knowledge Scale was alpha tested among a stratified sample of 40 LVAD patients, candidates, and decliners. Results: Results of cognitive interviewing and alpha testing demonstrated that these methodologies were effective in creating a measure to capture and assess patient beliefs, understandings and values about treatment options. The scale showed good internal consistency (Cronbach’s α  = .89) and was significantly correlated with both the Decisional Regret Scale (r= .89, p< .05) and

the Montreal Cognitive Assessment (MOCA) tool (r= .76, p< .05). Further, the scale takes only 10-15 to administer. Conclusion: Our results show that the inductive methodologies outlined in this paper can be effectively applied across settings and other clinical treatment areas to create valid and robust measures of knowledge that are responsive to individual patient preferences, needs and values, and help to ensure that patient values guide clinical decision-making. 9( 40) Results of the HVAD Outpatient Management and Monitoring Survey for Optimal Outcomes T. Schlöglhofer ,1 D. Robson,2 J. Bancroft,3 G. Soerensen,4 F. Kaufmann,5 L. Sweet,6 N. Wrightson.7  1Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; 2St. Vincent’s Hospital, Sydney, Australia; 3Prince Charles Hospital, Brisbane, Australia; 4Department of Cardiothoracic and Vascular Surgery, Oslo University Hospital, Oslo, Norway; 5Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany; 6HeartWare Inc., Framingham, MA; 7Freeman Hospital, Newcastle upon Tyne, United Kingdom. Purpose: The HeartWare® left ventricular assist device (HVAD) is successfully being used as a bridge-to-transplant and destination therapy in end-stage heart failure patients. To enhance patient functional status and outcomes optimal patient management is required. The aim of this study was to assess the different long-term HVAD patient management and monitoring strategies in various international heart centers. Methods: A survey containing 24 questions (multiple answer choices) about what, when and how to monitor in HVAD patients was sent out to 86 international (excluding the United States) VAD coordinators representing different centers. Questions covered topics related to site organization, anticoagulation, driveline exit site dressing and showering, blood pressure and pump parameter monitoring, and patient discharge. Results: Responses were received by 42% (N= 36) of the invited participants. Respondents were VAD coordinators representative of small, medium and large VAD implant centers. Following initial discharge, 20% of patients go immediately to rehabilitation center and 46% directly to home. Most centers (28%) measure outpatient INRs every 3-4 days, and the most frequent schedule for driveline exit site dressing changes is 3 times per week (31%). Interestingly, 14% of the centers do not allow their patients to shower, despite the availability of shower bags. It was also interesting to find that only 25% of centers are requiring their patients to measure blood pressure at home, although recent data suggesting strong correlations of elevated blood pressure (> 90mmHg) with strokes and VAD thrombus. Conclusion: Patient management varies significantly among different heart centers. Careful adherence to patient management guidelines will optimize outcomes and improve patient quality of life. 9( 41) Functional Outcomes of Left Ventricular Assist Device Patients Receiving Inpatient Rehabilitation L.A. Coyle , K. Milkevitch, R. Adair, A. Tatooles, G. Bhat.  Advocate Christ Medical Center, Oak Lawn, IL. Purpose: The functional independence measure (FIM) scale provides a uniform system of measurement to assess physical and cognitive disability. We studied the functional outcomes of patients with a left ventricular assist device (LVAD) who completed an inpatient rehabilitation unit (IRU) program. Methods: A single center retrospective study of all patients (n= 90) who received inpatient rehabilitation after initial implant with a continuous flow LVAD from March of 2009 through Sept 2014 was performed. Patients who required inpatient rehab after a device exchange or following a complication after initial discharge were excluded. Demographic, clinical and functional data were collected. IRU length of stay (LOS), discharge disposition, and FIM scores were examined. Results: The majority (88%) of patients who received inpatient rehab were implanted for destination therapy. The mean IRU length of stay was 16.2 ± 6.9 days. The mean admission FIM score was 62 ± 10.9 and discharge FIM score was 89.7 ± 10.9. The FIM gain was statistically significant at 28.4 ± 12.3 (p < 0.0001), and compared favorably to benchmarks for mean FIM

S338

The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015

gains at our facility (26.4), regionally (21.5) and nationally (22.7) for patients admitted to IRUs with a cardiac diagnosis. The FIM efficiency (FIM gain/ IRU LOS) was 1.9 ± 1.0 compared with the mean FIM efficiency at our facility (2.2), regionally (2.1) and nationally (2.2). 74% (n= 67) of patients were discharged directly home after inpatient rehabilitation, 17% (n= 16) were readmitted to the acute hospital service and 8% (n= 7) required additional rehabilitation at a subacute rehab facility. Conclusion: Patients with a LVAD achieve clinically meaningful functional gains from inpatient rehabilitation with the majority of patients being discharged home. Further studies need to be performed to analyze clinical outcomes after inpatient rehabilitation. 9( 42) System of Donor Hospital Transplant Coordinators Maintained and Financed By National Transplant Organization Improves Donation Rates T. Danek,1 J. Czerwiński,2 I. Milaniak ,3 M. Trujnara,4 A. Parulski,5 P. Przybylowski,6 R. Danielewicz.2  1Polish Transplant Coordinating Center Poltransplant, Warszawa, Poland; 21. Polish Transplant Coordinating Center Poltransplant 2. 2Department of Surgical and Transplant Nursing, Medical University of Warsaw, Warszawa, Poland; 31. John Paul II Hospital 2. Andrzej Frycz Modrzewski Krakow University, Faculty of Health and Medical Science 3. Polish Transplant Coordinating Center Poltransplant, Warszawa/Krakow, Poland; 4Department of Anaesthesiology and Intensive Therapy, Międzyleski Specialistic Hospita, Warszawa, Poland; 5Department of Cardiosurgery, The Cardinal Stefan Wyszyński Institute of Cardiology, Warszawa, Poland; 6Jagiellonian University Collegium Medicum, Krakow, Poland. Purpose: The study evaluated: - if the system (nationwide, maintained and funded by national organization) is sufficient, - if it improved DBD donation rates and hospital activities. Methods: Donation indicators in 30 months period of coordinators’ work, were compared to the 30 months period prior to their employment; 2) the number of hospitals with positive effect and with no effect was analyzed totally in the country and in groups of hospitals with specific profiles. Results: Implemented system: 1) resulted in increasing the number of potential donors by 33%, effective by 31,5%, increasing utilized organs by 28,7% and multiorgan retrievals from 53,5% to 57,6%, decreasing of the rate: utilized organs/actual donors from 2,66 to 2,61 2) positive effect was achieved in 121 (62%) hospitals (better results in regions, where donation were initially low - 73%, university hospitals - 69%, hospitals in large cities - 82%, hospitals with two coordinators - 74%, hospitals for adults - 62%, where the coordinator was doctor not nurse. Conclusion: The system resulted globally in increasing donation rates but is effective only in 62% of hospitals. In remaining additional activities should be introduced (quality systems, trainings, techniques for monitoring potential of donation, changes in profile of a coordinator). Formal analysis of coordinators activities gives also the national organization a rational basis for their employment policy taking into account the characteristics of hospitals and coordination teams. 9( 43) WITHDRAWN 9( 44) De Novo Development of Pulmonary Arterial Hypertension in Association With Pregnancy: A Retrospective Case Series L. Harper ,1 J. Swiston,2 R. Levy,2 N. Brunner,3 J. Grewal,3 M. Idrees,2 M. Kiess.3  1University of British Columbia, Vancouver, BC, Canada; 2Division of Respirology, University of British Columbia, Vancouver, BC, Canada; 3Division of Cardiology, University of British Columbia, Vancouver, BC, Canada. Purpose: Pulmonary arterial hypertension (PAH) is an uncommon condition characterized by increased pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) with normal pulmonary arterial wedge pressure (PAWP). PAH can be idiopathic or associated with a number of conditions including connective tissue diseases, congenital heart disease, liver disease, drug exposure and HIV. Despite new targeted therapies, PAH carries a high maternal mortality rate

and pregnancy remains generally contraindicated. There is a poorly-characterized subset of patients in whom PAH appears to develop de-novo in association with pregnancy. The relationship between PAH and pregnancy is to date not fully understood. Concepts regarding pathophysiology have primarily been focused on the hemodynamic changes of pregnancy unmasking previously undiagnosed disease in an affected individual, rather than new disease onset. Methods: All consecutive patients at the Vancouver Pulmonary Hypertension Clinic from June 2000 to December 2014 were reviewed to identify cases in which the initial presentation and/or diagnosis of PAH was made during pregnancy or in the postpartum period. Baseline characteristics, functional classification, hemodynamic parameters, functional testing and final diagnosis were anonymized and tabulated. Results: We identified 6 patients diagnosed with PAH during pregnancy or postpartum in whom there was no indication that PAH antedated the pregnancy. Of the 6 patients, 4 had iPAH, 1 SLE-related PAH, and 1 HIV-related PAH. Based on rigorous medical history, we believe all 6 patients had denovo disease, which developed in association with pregnancy. Conclusion: A diagnosis of PAH during pregnancy carries significant risk for mother and child, and poses great challenge for PAH specialists. The relationship between pregnancy and de-novo development of PAH is still not fully understood and remains an area requiring further study.

Table 1:

Presenting features and diagnosis of 6 cases.

Case

1

2

Ethnicity

Caucasian

First Nations Caucasian

Comorbid conditions

None Vitiligo, chronic idiopathic urticaria, IBS

3

Borderline protein C deficiency

4

5

6

Caucasian

First Nations

First Nations

HIV, hepatitis Hypertension SLE, remote C, remote cholecystectomy IVDU, anxiety

24 Gestational age at symptom onset (weeks)

35

4 postpartum 2 postpartum

2 postpartum 32

Modified NYHA III functional class at diagnosis

III

II-III

IV

III

II

92/43 (60)

97/32 (60)

PASP 65 by echocardiography

PAP by RHC at 93/32 (53) 77/38 (54) 74/42 (54) presentation (mmHg) 3

12

16

9

N/A

PVR by RHC at 15 presentation (mmHg)

18

14

15

16

N/A

6MWT at diagnosis (m)

300

234

200

305

N/A

N/A

Final diagnosis

iPAH

iPAH

iPAH

HIV-related PAH

iPAH

SLE-related PAH

PAWP by RHC at presentation (mmHg)

7

9( 45) Pulmonary Arterial Hypertension in the Setting of Pregnancy M. Lyle ,1 E. Fenstad,2 K. Arendt,3 R. Frantz,2 H. Connolly,1 C. Warnes,2 G. Kane.2  1Internal Medicine, Mayo Clinic, Rochester, MN; 2Cardiovascular Diseases, Mayo Clinic, Rochester, MN; 3Anesthesiology, Mayo Clinic, Rochester, MN. Purpose: Pulmonary arterial hypertension (PAH) is associated with peripartum complications. This study describes clinical outcomes and echocardiographic findings of patients with PAH in the setting of pregnancy. Methods: Single center cohort study of all patients with pulmonary hypertension (PH) evaluated between 1/1/1995 - 1/31/2014 who presented during pregnancy or within one year postpartum. PH defined as mean pulmonary artery pressure (PAP) ≥  25 mmHg. Results: Of 13 patients evaluated for PH and pregnancy, there were 12 with idiopathic PAH and one with chronic thromboembolic PH. Two (15%) were diagnosed with PAH prior to pregnancy, both with minimal right ventricular dysfunction and mild tricuspid regurgitation. Of these two, one terminated the