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Heart Transplantation in Giant Cell Myocarditis: A Contemporary Analysis of the UNOS Database
S124 Journal of Cardiac Failure Vol. 22 No. 8S August 2016 356 Heart Transplantation in Giant Cell Myocarditis: A Contemporary Analysis of the UNOS Database Chantal Elamm, Sadeer Al-Kindi, Guilherme Oliveira; UHHS, Cleveland, OH Background: Giant cell myocarditis (GCM) is a rare cause of cardiomyopathy that has an acute presentation and results in rapid deterioration,it is highly lethal with a rate of death or heart transplantation as high as 89%. There is little contemporary information on the clinical progression, mechanical circulatory support (MCS) needs and heart transplant outcomes of these patients. Objectives: To describe the contemporary natural history, requirements of MCS, wait list and post-transplant outcomes of patients with GCM listed for heart transplantation and compare them to those listed with idiopathic dilated cardiomyopathy(IDCMP). Methods: We used the UNOS thoracic organ transplantation files for this study. Patients with a diagnosis of GCM were identified and compared to IDCMP using comparative and survival analysis. Results: A total of 25 patients with GCM were compared with 18330 patients with IDCMP. Mean age at listing for GCM was 47.8 ± 11.2 years which was comparable with that of IDCMP 49.5 ± 12.2 years, P = .5, GCM patients were more likely to be white (92% vs 61%, P = .001), with a trend towards less male predominance (56% vs 72.1%, P = .078). Patients with GCM presented more acutely, with lower cardiac outputs and had a significantly greater need for MCS (69% in GCM vs. 19.2% in IDCMP) with a 30 fold greater need for an ECMO support and a 3 fold greater need for a ventricular assist device. They also had a 6 fold greater need for a ventilator support (16% vs 2.7%, P = .004). GCM patients were more likely to be listed as 1A (44% vs 16%, P < .001). Among the 25 GCM patients, 20 patients underwent transplantation, 2 patients died while waiting, 2 patients were transferred to different centers, and 1 patient had condition improved and transplantation was not needed. Time to death was not statistically different between GCM and IDCMP (24.0 vs 130.0 months, P = .889) while time to transplantation was shorter in GCM than IDCMP (6.9 vs 44.8 months, P = .005). At a median of 5.0 years post-transplantation, there were 6 deaths in the GCM group: primary graft failure (1), acute rejection (1), bacterial sepsis (1), MI (2), and cardiac arrest (1). Mean time to death was not statistically different between GCM and IDCMP (11.3 vs 10.9 years, P = .892).There was a trend towards increased acute rejection in GCM in the index hospitalization (27.3 vs 9.5, P = .079), but there was no difference in rejection within 1 year (32.8% vs 25%, P = .762). Conclusion: Compared with IDCMP, patients with GCM present more acutely with a significantly greater need for mechanical circulatory and ventilator support. They were more often listed as status 1 A with shorter wait list, their post transplantation survival and rejection rates were comparable at 1 year follow up.
spective review was conducted on 100 consecutive patients who received continuous flow LVADs over a three year period (2011 and 2014) who were administered The Montreal Cognitive Assessment (MoCA) at the time of their pre-surgical psychological evaluation. Those who did not survive to discharge were excluded. Demographic information, MoCA scores and patient outcomes were collected. The primary endpoint of interest was time to hospital readmission tested using Cox regression models adjusted for potential confounders (age, race, gender, indication, and INTERMACS category). Comorbidity burden was assessed using the Charlson index. Standard MoCA subscores for Executive function, Attention, Naming, Abstraction, Language, and Orientation were tested as categorical variables (dichotomized at the median). Results: Average age was 55.6 (±12.29), 22% were female (n = 22), 42% were non-white race (n = 42), and 69% were destination therapy (n = 69). Charlson index was higher in patients with worse baseline MoCA (mean 4.5 vs 3.6, P = .021), but this did not impact the association of MoCA score with time to readmission (Charlson p = NS, MoCA category P = .005 HR = 2.0). When each subscore was tested in regression models only Attention was associated with risk of readmission (HR 2.5, P = .029). Conclusions: Among patients receiving LVADs, baseline cognitive dysfunction is associated with a greater burden of comorbidities, but this did not account for the increased hospital readmission rates among cognitively impaired patients. The cognitive domain that appears most important to post-LVAD outcomes is Attention/Concentration; the mechanism involved is unclear and deserves further investigation.
358 Body Mass Index Does Not Impact Short-Term Functional Recovery during Inpatient Rehabilitation after Left Ventricular Assist Device Implantation Saurabh Gupta, Ranjit John, Elizabeth Larsen, Rebecca Cogswell; University of Minnesota, Minneapolis, MN Introduction: It has been previously demonstrated that inpatient rehabilitation leads to improvement in Functional Independence Measure (FIM) scores after left ventricular assist device (LVAD) implantation. Whether body mass index impacts rehabilitation potential in this population remains unknown. Hypothesis: FIM score improvement will be decreased in LVAD recipients who are at the extremes (high or low) of body weight. Methods: We performed an IRB-approved, retrospective review of all patients with new LVAD implantation or pump exchange at our tertiary care center between 2009 and 2014. Patients who were discharged to Inpatient rehabilitation Facility (IRF) were identified and Demographics, medical comorbidities, reason for LVAD, BMI, length of stay (LOS), and FIM scores (Functional Independence Measure— uniform system of measurement for disability based on the International Classification of Impairment, Disabilities and Handicaps) on admission and discharge were recorded. Patients were divided into four admission BMI categories: underweight (<19.5 kg/m2), normal (19.5–29 kg/m2), obese (30–35 kg/m2), extremely obese (>35 kg/ m2). Mean FIM gain and FIM efficiency (FIM gain/length of stay) was calculated for each BMI category and compared. Results: Ninety-four LVAD patients had FIM scores available and were included in the analysis. The mean age of the cohort was 62 +/− 10 years and the 67 (71%) of the patients were designated as bridge to transplant. The obese (obese and extremely obese) groups had a higher percentage of patients with diabetes than the non-obese category patients (Table). FIM scores improved significantly with inpatient rehabilitation in all groups (P < .05, all categories). BMI was not associated with FIM gain (P = .20) or FIM efficiency (0.40) in this analysis. Conclusion: Patients who underwent inpatient rehabilitation after LVAD implantation showed significant improvement in functional gains, independent of BMI. Further studies are necessary to determine whether BMI impacts long-term motor and cognitive recovery in LVAD recipients. Table: Baseline characteristics and Functional Independence Measures in LVAD recipients by body mass index category.
BMI: category <19.5 kg/m2 19.5–30 kg/m2 30–35 kg/m2 >35 kg/m2 n=5
357 Cognitive Functioning and Post-LVAD Outcomes:Influence of Comorbidities and Specific Cognitive Domains Kelly Bryce, Melody Pehote, David Lanfear; Henry Ford Hospital, Detroit, MI Introduction: Left ventricular assist devices (LVAD) are accepted therapy for end stage heart failure, but optimal patient selection remains challenging. Our group and others recently showed that baseline cognitive impairment is associated with worse outcomes post LVAD. We investigated whether this was impacted overall comorbidity burden, and which dimensions of cognitive function were most critical. Methods: A retro-
Mean BMI CKD Diabetes BTT Age INTERMACS Admission FIM Discharge FIM FIM gain FIM efficiency
18 +/− 1.0 3(60) 0(0) 4 (80) 59 +/− 9 4 +/− 1 68 +/− 15 92 +/− 18 24 + /-14 2.4 +/− 1.6
n = 61 26 +/− 3 19(31) 15(25) 42(69) 64 +/− 10 3.6 +/− 1.6 77 +/− 12 98 +/− 15 21 + /-14 2.3 +/− 1.7
n = 20 32 +/− 2 7(35) 11(55) 13 (65) 61 +/− 12 3.7 +/− 1.5 81 +/− 9 101 +/− 14 20 +/− 10 2.5 +/− 1.8
n = 10
P value
37 +/− 2 5(50) 6(60) 8 (80) 59 +/− 9 3.2 +/− 1.4 77 +/− 13 101 +/− 11 23 +/− 18 2.5 +/− 1.1
na .41 <.01 .89 .72 .75 .34 .68 .20 .40
Legend: BMI: body mass index, CKD: chronic kidney disease, BTT: bridge to transplant, FIM:Functional Independence Measures, FIM efficiency: FIM gain/length of stay (days.
spective review was conducted on 100 consecutive patients who received continuous flow LVADs over a three year period (2011 and 2014) who were administered The Montreal Cognitive Assessment (MoCA) at the time of their pre-surgical psychological evaluation. Those who did not survive to discharge were excluded. Demographic information, MoCA scores and patient outcomes were collected. The primary endpoint of interest was time to hospital readmission tested using Cox regression models adjusted for potential confounders (age, race, gender, indication, and INTERMACS category). Comorbidity burden was assessed using the Charlson index. Standard MoCA subscores for Executive function, Attention, Naming, Abstraction, Language, and Orientation were tested as categorical variables (dichotomized at the median). Results: Average age was 55.6 (±12.29), 22% were female (n = 22), 42% were non-white race (n = 42), and 69% were destination therapy (n = 69). Charlson index was higher in patients with worse baseline MoCA (mean 4.5 vs 3.6, P = .021), but this did not impact the association of MoCA score with time to readmission (Charlson p = NS, MoCA category P = .005 HR = 2.0). When each subscore was tested in regression models only Attention was associated with risk of readmission (HR 2.5, P = .029). Conclusions: Among patients receiving LVADs, baseline cognitive dysfunction is associated with a greater burden of comorbidities, but this did not account for the increased hospital readmission rates among cognitively impaired patients. The cognitive domain that appears most important to post-LVAD outcomes is Attention/Concentration; the mechanism involved is unclear and deserves further investigation.
358 Body Mass Index Does Not Impact Short-Term Functional Recovery during Inpatient Rehabilitation after Left Ventricular Assist Device Implantation Saurabh Gupta, Ranjit John, Elizabeth Larsen, Rebecca Cogswell; University of Minnesota, Minneapolis, MN Introduction: It has been previously demonstrated that inpatient rehabilitation leads to improvement in Functional Independence Measure (FIM) scores after left ventricular assist device (LVAD) implantation. Whether body mass index impacts rehabilitation potential in this population remains unknown. Hypothesis: FIM score improvement will be decreased in LVAD recipients who are at the extremes (high or low) of body weight. Methods: We performed an IRB-approved, retrospective review of all patients with new LVAD implantation or pump exchange at our tertiary care center between 2009 and 2014. Patients who were discharged to Inpatient rehabilitation Facility (IRF) were identified and Demographics, medical comorbidities, reason for LVAD, BMI, length of stay (LOS), and FIM scores (Functional Independence Measure— uniform system of measurement for disability based on the International Classification of Impairment, Disabilities and Handicaps) on admission and discharge were recorded. Patients were divided into four admission BMI categories: underweight (<19.5 kg/m2), normal (19.5–29 kg/m2), obese (30–35 kg/m2), extremely obese (>35 kg/ m2). Mean FIM gain and FIM efficiency (FIM gain/length of stay) was calculated for each BMI category and compared. Results: Ninety-four LVAD patients had FIM scores available and were included in the analysis. The mean age of the cohort was 62 +/− 10 years and the 67 (71%) of the patients were designated as bridge to transplant. The obese (obese and extremely obese) groups had a higher percentage of patients with diabetes than the non-obese category patients (Table). FIM scores improved significantly with inpatient rehabilitation in all groups (P < .05, all categories). BMI was not associated with FIM gain (P = .20) or FIM efficiency (0.40) in this analysis. Conclusion: Patients who underwent inpatient rehabilitation after LVAD implantation showed significant improvement in functional gains, independent of BMI. Further studies are necessary to determine whether BMI impacts long-term motor and cognitive recovery in LVAD recipients. Table: Baseline characteristics and Functional Independence Measures in LVAD recipients by body mass index category.
BMI: category <19.5 kg/m2 19.5–30 kg/m2 30–35 kg/m2 >35 kg/m2 n=5
357 Cognitive Functioning and Post-LVAD Outcomes:Influence of Comorbidities and Specific Cognitive Domains Kelly Bryce, Melody Pehote, David Lanfear; Henry Ford Hospital, Detroit, MI Introduction: Left ventricular assist devices (LVAD) are accepted therapy for end stage heart failure, but optimal patient selection remains challenging. Our group and others recently showed that baseline cognitive impairment is associated with worse outcomes post LVAD. We investigated whether this was impacted overall comorbidity burden, and which dimensions of cognitive function were most critical. Methods: A retro-
Mean BMI CKD Diabetes BTT Age INTERMACS Admission FIM Discharge FIM FIM gain FIM efficiency
18 +/− 1.0 3(60) 0(0) 4 (80) 59 +/− 9 4 +/− 1 68 +/− 15 92 +/− 18 24 + /-14 2.4 +/− 1.6
n = 61 26 +/− 3 19(31) 15(25) 42(69) 64 +/− 10 3.6 +/− 1.6 77 +/− 12 98 +/− 15 21 + /-14 2.3 +/− 1.7
n = 20 32 +/− 2 7(35) 11(55) 13 (65) 61 +/− 12 3.7 +/− 1.5 81 +/− 9 101 +/− 14 20 +/− 10 2.5 +/− 1.8
n = 10
P value
37 +/− 2 5(50) 6(60) 8 (80) 59 +/− 9 3.2 +/− 1.4 77 +/− 13 101 +/− 11 23 +/− 18 2.5 +/− 1.1
na .41 <.01 .89 .72 .75 .34 .68 .20 .40
Legend: BMI: body mass index, CKD: chronic kidney disease, BTT: bridge to transplant, FIM:Functional Independence Measures, FIM efficiency: FIM gain/length of stay (days.