Impact of Donor and Recipient Socio-economic Status (SES) on Outcomes in Adult Heart Transplantation: Does It Really Matter?

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The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014

or cognitive impairment. Of the 47 patients with heart failure, 34 patients (72%) had some degree of frailty. Frailty in the heart failure group was not associated with age, left ventricular ejection fraction or ventricular assist device use. Of the 31 patients with lung failure, 20 patients (65%) had some degree of frailty. Frailty in the lung failure group was not associated with any lung failure severity index measured. Conclusion: This study has determined for the first time the prevalence of the frailty syndrome in patients being assessed for heart or lung transplantation. Although some degree of frailty is common in advanced heart and lung failure, only a small percentage met the Fried Criteria for the frailty phenotype. Interestingly, the frailty phenotype was unrelated to age or disease severity in this population. 3( 30) Depression and Social Isolation at Time of Wait Listing Reduce Survival Up to 5 Years After Heart Transplantation - Results from the Waiting for a New Heart Study H. Spaderna ,1 S. Hellwig,1 T. Schäfer,2 F.M. Wagner,2 J.M. Smits,3 G. Weidner.4  1Psychology, University of Wuppertal, Wuppertal, Germany; 2Klinik und Poliklinik für Herz- und Gefäßchirurgie, Universitäres Herzzentrum Hamburg, Hamburg, Germany; 3Eurotransplant International Foundation, Leiden, Netherlands; 4Biology, San Francisco State University, San Francisco, CA. Purpose: In the ongoing Waiting for a New Heart Study depression and social isolation were associated with pre-transplant outcomes such as receiving a ventricular assist device or heart transplantation (HTx) in high urgency status (Spaderna et al., JHLT 2012;31:16-26). We now have data on 148 patients who received a HTx, allowing to evaluate depression and social isolation assessed at time of listing as predictors of post HTx survival, considering type of transplantation (elective versus in high urgency status). Methods: The Waiting for a New Heart Study is a prospective observational multisite study of 318 HTx candidates who were registered with Eurotransplant (ET) between 2005 and 2006. Demographic and psychosocial characteristics were assessed by questionnaires at time of listing. ET provided medical baseline data, transplantation dates, and donor characteristics, hospitals reported medical data at time of HTx and post-transplant survival until February 2013. Results: Depressive symptoms and social isolation were unrelated and did not correlate with disease severity. During a median follow-up of 2.148 days (range 1-2.837 days), 56 (38%) of HTx recipients had died (39% after HU HTx, 34% after elective HTx). In univariate analyses, higher depression scores significantly increased the risk of dying (HR =  1.07, 95% CI [1.01, 1.15], p =  .04), a similar trend emerged for social isolation (HR =  1.04, 95% CI [0.99, 1.11], p =  .07). Cox proportional hazards analyses controlling for donor and recipient age and sex, creatinine, and other factors known to influence post HTx survival, revealed a significant interaction of depression with social isolation (HR =  0.98, 95% CI [0.97, 1.00], p =  .02). Survival after HTx was highest for patients without depressive symptoms who were not socially isolated at time of listing. This was particularly relevant for patients after HTx in high urgency status (p =  .02). Conclusion: Decreasing depressive symptoms and increasing social contacts among patients with advanced heart failure may help prevent poor outcomes after cardiac transplantation. 3( 31) Relationship Between Candidate Psychosocial Risk Profile, PostImplant Medical Compliance and Clinical Outcomes of LVAD Therapy K. Woodhouse ,1 K. Lietz,2 A. Branch,2 J. Spruill,2 L. Lewis-McGowan,2 M. McGrath,2 J. Herre.2  1Division of Advanced Heart Failure, Sentara Norfolk General Hospital, NOorfolk, VA; 2Division of Advanced Heart Failure, Sentara Norfolk General Hospital, Norfolk, VA. Purpose: Although psychosocial risk factors play an important role in candidate selection for LVAD therapy, their impact on long-term clinical outcomes remains unknown. In this study, we sought to examine the relationship between candidate psychosocial risk profile, post-implant medical adherence and clinical outcomes of LVAD recipients.

Methods: We studied 116 consecutive recipients of de novo HeartMate II LVAD at our center between Jan 2009 and July 2013 (46% DT, 21% BTT, 27% BTD) who were followed in the Advanced Heart Failure Clinic (76% male, 59% African American ethnicity, mean age 53±13 years, 59% non-ischemic). Psychosocial risk profile included education level, neurocognitive function, motivation, social and financial support, transportation, housing and histories of psychiatric illness, depression, tobacco and substance abuse, medical non-adherence, incarceration. Post-implant medical adherence was graded according to the published non-compliance scale. Candidate psychosocial risk profile and post-implant medical noncompliance was then correlated with the number and cause of readmissions, pump durability and patient survival, as well as the costs of outpatient and inpatient care. Patients were followed until transplant, death or day of last observation on Aug 1, 2013 (mean follow-up was 16 months; 10 days to 4 years). Results: The majority of the studied (75%) patients had at least one psychosocial risk factor prior to implantation. There was a significant relationship between the degree of post-implant medical noncompliance and low level of education, low motivation, h/o tobacco and substance abuse and personality disorder (t-test, p< 0 .05 for all). Preoperative psychosocial risk factors and post-implant medical noncompliance, however, showed no significant correlation with the number or cause of readmissions, length of hospital stay, pump durability or patient survival. The average outpatient and inpatient costs of care were not affected by the psychosocial risk profile or medical non-compliance (p= NS). Conclusion: Although candidate psychosocial risk profile is an important predictor of medical non-adherence after hospital discharge, we did not find these risk factors predictive of clinical outcomes or costs of LVAD therapy. 3( 32) Impact of Donor and Recipient Socio-economic Status (SES) on Outcomes in Adult Heart Transplantation: Does It Really Matter? J.L. Nixon , R.O. McCubrey, D. Budge, E.M. Gilbert, R.A. Alharethi, B. Reid, S.G. Drakos, M.D. Everitt, J. Stehlik, K.M. Molina, J. Fang, J. Doty, A.G. Kfoury.  UTAH Cardiac Transplant Program, Salt Lake City, UT. Purpose: Low SES has been shown to be an independent risk factor for poor cardiovascular health and mortality due to cumulative effects of chronic stress, poor nutrition and other unknown variables. Beyond the short-term post-transplant phase, comorbidities play an immense role in longevity and quality of life. Whether donor SES has lasting effects on outcomes in heart transplant recipients and how it interplays with recipient SES is unknown and the topic of interest in this study. Methods: The United Network for Organ Sharing data base was queried for adult heart transplant recipients from 2007-2012. A composite SES score was derived based on eight variables from US census data by zip code. SES was stratified into high and low groups. Outcomes included length of hospital stay, graft failure, and rejection. Additional outcomes included post-transplant complications of stroke and need for dialysis or pacemaker. Outcomes were evaluated using ANOVA, Breslow-day tests, and cox-proportional models as appropriate. Results: Based on OPTN data as of 6/7/2013, 13,615 patients were transplanted and 8,062 met inclusion criteria. With high donor SES, high SES recipients were 67% less likely to require dialysis post-transplant then low SES recipients (p= 0.0282). Also with high donor SES, there was a significant increase in long-term survival for high SES recipients (p= 0.0096) (graph 1). With low donor SES, there was no difference in need for dialysis or longterm survival for low or high SES recipients. There was no difference in one year graft survival for any SES combination. Ischemic time, length of hospital stay, stroke, need for pacemaker, and rejection were not different based on SES. Conclusion: Donor SES may have implications for long-term survival and need for dialysis in heart transplant recipients. Perhaps a priori knowledge of donor SES could be useful in decisions regarding the need for more aggressive control of comorbidities post-transplantation in hopes of improving outcomes.

Abstracts S127 

Methods: We retrospectively examined medical records of 71 patients who underwent placement of a HeartMate II or HeartWare LVAD at our institution. Insurance status was determined at the time of implantation. Medical record was examined to assess clinical outcomes such as survival, attainment of insurance, and transplant candidacy. Results: We identified 14 uninsured patients (20% of total LVAD population) who underwent LVAD implantation. Uninsured patients were younger and less likely to have ischemic etiology for heart failure than insured patients (see table). All patients postoperatively eventually attained insurance benefits (Medicare or Medicaid). Clinical outcomes were as follows: 7 patients (50%) were eventually listed for transplantation with 4 undergoing transplant and 3 currently listed, 5 patients (36%) with ongoing support as destination therapy, and 2 deaths (14%) within the first year (cerebrovascular accident in both). Conclusion: Uninsured patients can undergo LVAD implantation with successful outcomes. LVAD implantation can allow for patients to stabilize while insurance is obtained, allowing for eventual listing for transplantation. Given the high costs associated with chronic heart failure, further research is needed to determine if LVAD placement in uninsured advanced heart failure patients can reduce overall health care expenditures.

Patient Demographics

3( 33) Socio-Economic Classification Is a Predicator of Long Term Survival in Patients With Left Ventricualr Assist Device N. Robinson Smith , N. Wrightson, A. Woods, G. MacGowan, S. Schueler.   Mechanical Circulatory Support Team, The Newcastle upon Tyne NHS Trust, Newcastle upon Tyne, United Kingdom. Purpose: The influence of socioeconomic status on health outcomes are well described, though little is published on long term survival in patients with the highly complex therapy of LVAD. Methods: We analysed a total of 88 patients who had undergone implantation of a 3rd generation device (VentrAssist N= 5, HeartWare N= 83) and who had been successfully discharged home. Duration of follow up was from 2 months to 58 months. Patients were divided into 3 social classes using the UK National Statistics Socio-Economic Classification (1= higher occupations, 2= intermediate occupations, 3= lower occupations). Compliance with therapy was also analysed. Results: In patients groups 1+2 combined 1 year survival was 94% and two year survival also 94%. In group 3, 1 year survival was 81% and 2 year survival 71% (P< 0.05). Compliance with therapy did not predict outcomes. Readmissions were similar in all groups (group 1: 2.7 admissions/patient, group 2: 3.4, group 3: 3.6). Conclusion: Higher socio-economic status is a powerful predictor of survival on a LVAD. The home based care of a LVAD is both complex and challenging, with issues relating to driveline wound care to prevent infection, selftesting of anticoagulation and the monitoring of the LVAD settings. These findings suggest that intense and regular patient education efforts should be targeted to those patients who have attained a lesser degree of education and socioeconomic status in order to improve long term survival in this vulnerable cohort of patients. 3( 34) Success of Left Ventricular Assist Device Therapy in Uninsured Patients N. Rajagopalan , K. Million, T.A. Tribble, D.R. Dennis, R. Yanagida, C.W. Hoopes.  University of Kentucky, Lexington, KY. Purpose: Given the complexity and cost associated with left ventricular assist devices (LVAD), the management of uninsured patients presenting with advanced heart failure is problematic. There is limited data on the utilization and outcomes of LVAD technology in patients who lack health insurance. Our purpose was to examine the outcome of uninsured LVAD patients implanted at our institution.

Age (yrs) Male gender (%) Ischemic etiology (%) INTERMACS profile

Insured(n =  57)

Uninsured(n =  14)

p value

54 ± 11 74% 52% 2.4 ± 1.0

42 ± 11 79% 36% 2.0 ± 1.0

<  0.01 NS <  0.01 NS

3( 35) A Zero 90-Day Mortality After Lung Transplantation - What Is the Price? M. Zemtsovski ,1 P.F. Jensen,1 M. Østergaard,1 M. Perch,2 D. Steinbrüchel,3 M. Iversen.2  1Department of Cardiothoracic Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; 2Department of Cardiology - Division of Lung Transplantation, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; 3Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. Purpose: During the last decade, the 90-day mortality after lung transplantation (LT) has been 2.8% at our center. The last two years it has decreased to zero. The aim of this study was to evaluate the hospital costs of the first 90 days after LT. Methods: A review of data of all patients receiving LT at The National Lung Transplant Center, Copenhagen University Hospital, Rigshospitalet, Denmark from 2011 to 2013. Results: From August 2011 to September 2013, 66 patients underwent LT (60 double and 6 single LT). Main indications were chronic obstructive pulmonary disease (n= 20), cystic fibrosis (n= 12), pulmonary fibrosis (n= 11), alpha1-antitrypsin deficiency (n= 10), sarcoidosis (n= 6), and other end-stage lung diseases (n= 7). The follow-up was complete in all cases. The median follow-up time was 336 days, range 53-772. We categorized patients into two groups depending on the length of stay in the ICU. In group A there were 7 patients, who had an ICU stay of more than 30 days (median 65, range 33-188). Fifty-nine patients (group B) had an ICU length of stay less than 30 days (median 3, range 1-28). Group A comprised 11% of recipients in total, but accounted for 59% of time in the ICU (447/758 days), 7% of time in the lung transplantation ward (163/2282 days), and 35% ($2.04/5.86 million) of hospital costs during the first 90 days after LT. The cumulative mortality for the entire series was 15% (n= 10), distributed between group A 57 % (n= 4) and group B 10% (n= 6), respectively (p< 0.001), see Figure. Main causes of mortality were graft failure secondary to pneumonia (n= 3), restrictive allograft syndrome (n= 1), and bronchial stenosis (n= 1), multiple organ failure (n= 2), septic shock (n= 1), air embolism (n= 1) and donor transmitted malignancy (n= 1). Conclusion: Modern intensive care can reduce early mortality at 90 days after LT close to zero. As a result of this, a minority of recipients with the longest