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Hospital Readmissions After Left Ventricular Assist Device Implantation Are Associated With Poor Outcomes: A Single Center Experience
S198
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
prosthetic graft related infections. The accuracy of PET-CT in identifying LVAD infections is unknown. Methods: Beginning in March 2013, all patients with any suspicion of LVAD infection, or known active infection receiving treatment, underwent PET-CT imaging (n= 13). Randomly selected patients on VAD ≥ 6 months without suspicion of infection served as controls (n= 7). Infection could involve the driveline, pump pocket, or be related to bacteremia. PET/CT scans were scored as to the presence of abnormally increased metabolic activity (Yes/ No) at the LVAD pocket, inflow cannula (IC), outflow cannula (OC), and the driveline. Results: Between March 2013 and August 2013, 23 PET/CT studies were performed in 20 patients. In the control group, 5 PET/CT studies were reported as no abnormal activity related to the LVAD, and none have gone on to develop an infection; of these patients, none had a VAD-related infection and were all from the control group. PET/CT scanning suggested LVAD pocket infection in 4/13 patients, which was confirmed on LVAD explant of these 4 patients. Importantly, one of these patients had a negative tagged WBC scan immediately pre-explant. Of patients without evidence of pocket infection on PET/CT imaging, 3 patients were explanted with no evidence of pocket infection. Driveline infection was suspected in 14 PET-CT studies, and in 11 of these patients infection was confirmed with positive culture data. Interestingly, the OC was reported as abnormal in 10 studies, but this would be an uncommon source of infection, and in explanted patients (5) only 1 had evidence of infection at this site. Two patients with chronic bacteremia had only OC abnormality on PET/CT imaging. Conclusion: PET/CT appears promising at detecting LVAD pocket infections, which significantly alters treatment plans regarding pump exchange and transplantation. A normal PET/CT may provide re-assurance regarding the absence of an LVAD infection. Increased uptake at the OC may represent a chronic inflammatory response to prosthetic graft material and not a marker of infection. 5( 32) Hospital Readmissions After Left Ventricular Assist Device Implantation Are Associated With Poor Outcomes: A Single Center Experience G. Ashrith , A.M. Cordero-Reyes, R.P. Vivo, C.M. Orrego, E.E. Suarez, B. Elias, M. Loebe, B.A. Bruckner, B.H. Trachtenberg, G. Torre-Amione, A. Bhimaraj, J.D. Estep. Cardiology, Houston Methodist Hospital, Houston, TX. Purpose: Repeat hospital admissions strongly predict higher mortality in patients with heart failure (HF) but there is a paucity of data regarding the implications of multiple hospital readmissions in patients supported with continuous-flow left ventricular assist devices (LVAD). We hypothesize that LVAD-associated readmissions have a negative impact on overall survival in this population. Methods: A total of 144 patients received an LVAD from 2008-2011 in a single center. Among patients who were discharged alive after LVAD implant, LVAD-associated hospital admissions were analyzed up to 1 year. Non-LVAD associated conditions and elective procedures were excluded. Patients who received a heart transplant within 1 year of LVAD were censored. The primary endpoint was death up to 1 year from last admission (survival was reset to a new time zero after each admission). Kaplan Meier survival curves were constructed for patients with 0, 1-2 and > 3 readmissions, p-values < 0.05 were considered significant. Results: The final study population was composed of 117 patients of these 61% were categorized as Destination Therapy (DT). Mean age was 56 ± 13 years, 73% were male. Mean time to 2nd readmission was 126 ± 90 days. There were no readmissions in 44 (38%) patients; 46 (39%) and 27 (23%) had 1-2 and > 3 readmissions, respectively. The average length of stay was 15 ± 21 days. Leading causes for readmissions were device-related infections (33%), bleeding events (26%), residual HF (11%), stroke (7%), LVAD malfunction due to pump thrombosis (6%) and arrhythmias (6%). There was a significant association between frequency of readmissions and overall survival: mean survival in patients with 0, 1-2 and > 3 readmissions were 89%, 72% and 67%, respectively (p = 0.03) (Figure). Conclusion: Based on our center’s experience in patients supported with continuous-flow LVAD primarily as destination therapy, more frequent hospital readmissions are associated with poor prognosis.
5( 33) Reducing 30 Day Hospital Readmissions for Patients with Left Ventricular Support Devices R.C. Starling ,1 T.J. Myers,2 R.R. Bostic,2 J.B. O’Connell,2 N.A. Mokadam,3 C.T. Salerno,4 R.L. Kormos.5 1Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH; 2Thoratec Corporation, Pleasanton, CA; 3Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA; 4Heart Transplant and Mechanical Assist Device Program, St. Vincent Heart Center of Indiana, Indianapolis, IN; 5Cardiothoracic Surgery, University of Pittsburgh Schools of the Health Sciences, Pittsburgh, PA. Purpose: Centers are concerned that implanting patients with left ventricular assist devices (LVAD) could negatively impact their overall heart failure readmission rate (RR) further triggering payment penalties from the Center for Medicare and Medicaid Services,. Reducing 30 day RR for patients supported by an LVAD is necessary to improve the cost effectiveness, acceptance, and overall “value” of the therapy. This study was designed to establish the current basis for recommending best practice guidelines for reducing 30 day RR in the LVAD population. Methods: A review of published articles addressing strategies for impacting readmission reduction of heart failure patients was completed to identify potential approaches that could be deployed in also reducing readmission in patients implanted with left ventricular assist devices. A questionnaire was sent to 127 Joint Commission centers certified for LVAD therapy for input. This tool queried what were the currently adopted practices by LVAD programs to reduce RR and to rank the effectiveness of each strategy. Results: Thirty-seven of 127 (29%) JC LVAD certified centers responded to the survey. Thirty-one centers (84%) reported performing more than 20 durable LVAD implants annually, and 21 (57%) had > 50 ongoing outpatients. The median reported 30-day readmission rate for LVAD patients was 20% (range; 5% to 37%). The most commonly reported causes of readmission from 10 categories are: GI bleeding, device infection (driveline), increased heart failure symptoms, other infection, and device malfunction. The majority of centers (73%) participate in one or more heart failure quality improvement programs; however, only 46% (15 of 33) report that these programs are applied to the LVAD population. The most common strategies for avoiding LVAD patient readmission are: optimized patient selection, improved patient education, early follow-up (telephone and clinic visit), and multidisciplinary discharge planning. Conclusion: The 30-day RR from our survey results was 20%, which is comparable to results from the INTERMACS Registry of 24%. The 5 best practices identified by the survey when incorporated into LVAD programs nationwide may reduce RR. This is an opportunity to develop and share best practices to provide improved chronic care to LVAD patients. The benefits are improved quality, a reduction in the LVAD RR and cost, and enhanced value. 5( 34) Hospital Readmission with LVAD Destination Therapy S. Klotz , E.I. Charitos, U. Stierle, H.H. Sievers. Dept. of Cardiac and Thoracic Vascular Surgery, University Hospital Schleswig-Holstein, Campus Luebeck, Luebeck, Germany. Purpose: Congestive heart failure (CHF) is the main reason for hospital readmission in the aging population. In addition left ventricular assist device
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
prosthetic graft related infections. The accuracy of PET-CT in identifying LVAD infections is unknown. Methods: Beginning in March 2013, all patients with any suspicion of LVAD infection, or known active infection receiving treatment, underwent PET-CT imaging (n= 13). Randomly selected patients on VAD ≥ 6 months without suspicion of infection served as controls (n= 7). Infection could involve the driveline, pump pocket, or be related to bacteremia. PET/CT scans were scored as to the presence of abnormally increased metabolic activity (Yes/ No) at the LVAD pocket, inflow cannula (IC), outflow cannula (OC), and the driveline. Results: Between March 2013 and August 2013, 23 PET/CT studies were performed in 20 patients. In the control group, 5 PET/CT studies were reported as no abnormal activity related to the LVAD, and none have gone on to develop an infection; of these patients, none had a VAD-related infection and were all from the control group. PET/CT scanning suggested LVAD pocket infection in 4/13 patients, which was confirmed on LVAD explant of these 4 patients. Importantly, one of these patients had a negative tagged WBC scan immediately pre-explant. Of patients without evidence of pocket infection on PET/CT imaging, 3 patients were explanted with no evidence of pocket infection. Driveline infection was suspected in 14 PET-CT studies, and in 11 of these patients infection was confirmed with positive culture data. Interestingly, the OC was reported as abnormal in 10 studies, but this would be an uncommon source of infection, and in explanted patients (5) only 1 had evidence of infection at this site. Two patients with chronic bacteremia had only OC abnormality on PET/CT imaging. Conclusion: PET/CT appears promising at detecting LVAD pocket infections, which significantly alters treatment plans regarding pump exchange and transplantation. A normal PET/CT may provide re-assurance regarding the absence of an LVAD infection. Increased uptake at the OC may represent a chronic inflammatory response to prosthetic graft material and not a marker of infection. 5( 32) Hospital Readmissions After Left Ventricular Assist Device Implantation Are Associated With Poor Outcomes: A Single Center Experience G. Ashrith , A.M. Cordero-Reyes, R.P. Vivo, C.M. Orrego, E.E. Suarez, B. Elias, M. Loebe, B.A. Bruckner, B.H. Trachtenberg, G. Torre-Amione, A. Bhimaraj, J.D. Estep. Cardiology, Houston Methodist Hospital, Houston, TX. Purpose: Repeat hospital admissions strongly predict higher mortality in patients with heart failure (HF) but there is a paucity of data regarding the implications of multiple hospital readmissions in patients supported with continuous-flow left ventricular assist devices (LVAD). We hypothesize that LVAD-associated readmissions have a negative impact on overall survival in this population. Methods: A total of 144 patients received an LVAD from 2008-2011 in a single center. Among patients who were discharged alive after LVAD implant, LVAD-associated hospital admissions were analyzed up to 1 year. Non-LVAD associated conditions and elective procedures were excluded. Patients who received a heart transplant within 1 year of LVAD were censored. The primary endpoint was death up to 1 year from last admission (survival was reset to a new time zero after each admission). Kaplan Meier survival curves were constructed for patients with 0, 1-2 and > 3 readmissions, p-values < 0.05 were considered significant. Results: The final study population was composed of 117 patients of these 61% were categorized as Destination Therapy (DT). Mean age was 56 ± 13 years, 73% were male. Mean time to 2nd readmission was 126 ± 90 days. There were no readmissions in 44 (38%) patients; 46 (39%) and 27 (23%) had 1-2 and > 3 readmissions, respectively. The average length of stay was 15 ± 21 days. Leading causes for readmissions were device-related infections (33%), bleeding events (26%), residual HF (11%), stroke (7%), LVAD malfunction due to pump thrombosis (6%) and arrhythmias (6%). There was a significant association between frequency of readmissions and overall survival: mean survival in patients with 0, 1-2 and > 3 readmissions were 89%, 72% and 67%, respectively (p = 0.03) (Figure). Conclusion: Based on our center’s experience in patients supported with continuous-flow LVAD primarily as destination therapy, more frequent hospital readmissions are associated with poor prognosis.
5( 33) Reducing 30 Day Hospital Readmissions for Patients with Left Ventricular Support Devices R.C. Starling ,1 T.J. Myers,2 R.R. Bostic,2 J.B. O’Connell,2 N.A. Mokadam,3 C.T. Salerno,4 R.L. Kormos.5 1Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH; 2Thoratec Corporation, Pleasanton, CA; 3Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA; 4Heart Transplant and Mechanical Assist Device Program, St. Vincent Heart Center of Indiana, Indianapolis, IN; 5Cardiothoracic Surgery, University of Pittsburgh Schools of the Health Sciences, Pittsburgh, PA. Purpose: Centers are concerned that implanting patients with left ventricular assist devices (LVAD) could negatively impact their overall heart failure readmission rate (RR) further triggering payment penalties from the Center for Medicare and Medicaid Services,. Reducing 30 day RR for patients supported by an LVAD is necessary to improve the cost effectiveness, acceptance, and overall “value” of the therapy. This study was designed to establish the current basis for recommending best practice guidelines for reducing 30 day RR in the LVAD population. Methods: A review of published articles addressing strategies for impacting readmission reduction of heart failure patients was completed to identify potential approaches that could be deployed in also reducing readmission in patients implanted with left ventricular assist devices. A questionnaire was sent to 127 Joint Commission centers certified for LVAD therapy for input. This tool queried what were the currently adopted practices by LVAD programs to reduce RR and to rank the effectiveness of each strategy. Results: Thirty-seven of 127 (29%) JC LVAD certified centers responded to the survey. Thirty-one centers (84%) reported performing more than 20 durable LVAD implants annually, and 21 (57%) had > 50 ongoing outpatients. The median reported 30-day readmission rate for LVAD patients was 20% (range; 5% to 37%). The most commonly reported causes of readmission from 10 categories are: GI bleeding, device infection (driveline), increased heart failure symptoms, other infection, and device malfunction. The majority of centers (73%) participate in one or more heart failure quality improvement programs; however, only 46% (15 of 33) report that these programs are applied to the LVAD population. The most common strategies for avoiding LVAD patient readmission are: optimized patient selection, improved patient education, early follow-up (telephone and clinic visit), and multidisciplinary discharge planning. Conclusion: The 30-day RR from our survey results was 20%, which is comparable to results from the INTERMACS Registry of 24%. The 5 best practices identified by the survey when incorporated into LVAD programs nationwide may reduce RR. This is an opportunity to develop and share best practices to provide improved chronic care to LVAD patients. The benefits are improved quality, a reduction in the LVAD RR and cost, and enhanced value. 5( 34) Hospital Readmission with LVAD Destination Therapy S. Klotz , E.I. Charitos, U. Stierle, H.H. Sievers. Dept. of Cardiac and Thoracic Vascular Surgery, University Hospital Schleswig-Holstein, Campus Luebeck, Luebeck, Germany. Purpose: Congestive heart failure (CHF) is the main reason for hospital readmission in the aging population. In addition left ventricular assist device