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Impact of Renal Dysfunction on Patients Undergoing Left Ventricular Assist Device Implantation
The 23rd Annual Scientific Meeting HFSA
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Surgery/Transplantation/Devices 438 Trans-Caval Impella 5.0: A Bridge to Recovery in Peripartum Cardiomyopathy Waleed Al-Darzi, Alexander Michaels, William O’Neill, Celeste T. Williams; Henry Ford Hospital, Detroit, MI Introduction: The incidence of peripartum cardiomyopathy (PPCMP) varies worldwide, the etiology is thought to be related to both environmental and genetic factors. The mortality rates are reported up to 16.7% and transplant rates up to 11%. The Interagency Registry for Mechanically Assisted Circulatory Support demonstrated improved myocardial recovery in PPCMP patients compared to non-PPCMP patients (6% vs. 1%) who required durable mechanical circulatory support devices (MCS). Our case demonstrates the use of trans-caval Impella 5.0 as a bridge to recovery in a PPCMP patient with cardiogenic shock post delivery. Clinical Presentation: 37-year-old woman with a history of PPCMP presented with progressive shortness of breath during the third trimester of pregnancy. She was found to have a decrease in left ventricular ejection fraction (LVEF) to 30-35% at 30 weeks gestation. Right heart catheterization showed RA 12 mmHg, PA 75/38 (50) mmHg, PCWP 30 mmHg, and CI 1.99 L/min/m2. She was transferred to Cardiac Intensive Care Unit (CICU) for invasive hemodynamic monitoring and tailored therapy. Nitroprusside was started with up titration of oral afterload reduction medications and continued intravenous diuresis. Due to preeclampsia, labor induction was initiated during week 34 of gestation. Secondary to multiple decelerations on fetal monitoring, an emergent primary C-section with bilateral tubal ligation was performed. Immediately after delivery, patient suffered hemodynamic collapse requiring emergent placement of a right femoral 2.5L Impella; noting small ilio-femoral arteries on angiography. There was no significant hemodynamic improvement (low cardiac index, elevated PA pressure, and progressive hypotension); patient was emergently upgraded to an Impella 5.0 via trans-caval approach under transesophageal echocardiogram guidance. Patient experienced cardiac arrest during procedure, with immediate ROSC. The Impella 5.0 placement was successful without complications and with improvement in hemodynamics (Improved CI from 1.3 to 1.6 L/min/m2, MAP from 55 to 88 mmHg, cardiac power output from 0.29 to 0.42 W), pH from 7.02 to 7.30. The 2.5L Impella removal was complicated by a right iliac artery rupture requiring a covered stent placement. CICU course was complicated by retroperitoneal hematoma, and acute renal failure requiring hemodialysis. Impella 5.0 was removed four days later; a 12/10 mm amplatz ductal occluder was used to close the transcaval arteriotomy site. Hemodialysis was discontinued 12 days post-delivery and her LVEF improved to 40-45%. She was discharged to rehab and had significant improvement in her functional capacity on her 6-week follow up. Conclusion: Close monitoring and prompt action to escalate hemodynamic support, with temporary MCS to achieve better outcomes in cardiogenic shock is imperative. Transcaval Impella 5.0 is a feasible alternative to extracorporeal membrane oxygenation and provides a high level of hemodynamic support which could bridge to myocardial recovery in PPCMP patients suffering from cardiogenic shock.
439 Impact of Renal Dysfunction on Patients Undergoing Left Ventricular Assist Device Implantation Aasim Afzal, Tariq Nisar, Aayla Jamil, Aaron Kluger, Joost Felius, Timothy Gong, Shelley Hall, Parag Kale; Baylor University Medical Center, Dallas, TX Background: Left ventricular assist devices (LVADs) are increasingly used as a bridge to transplant or destination therapy. Renal dysfunction often precludes patients from single organ heart transplantation. However, the effect of preoperative renal dysfunction on LVAD outcomes is often debated, with limited literature available. Hypothesis: Patients with preoperative chronic kidney disease undergoing LVAD implantation have worse periprocedural outcomes. Methods: All hospitalizations of patients with systolic heart failure with index LVAD implantation (ICD-9 procedure code 37.66) were identified from the 2008-2014 National Inpatient Sample. Patients were stratified based on whether they had preoperative chronic kidney disease (CKD stage 1-4) (diagnosis codes 585.X) or normal renal function. Outcomes including in-hospital mortality, LOS, cost of care, and postoperative complications were analyzed. Trends over time were determined using the Cochran Armitage and Cuzick tests. Multivariate models were constructed with logistic and linear regression (gamma function) using the discharge weights provided under NIS guidelines. These models were adjusted for age and comorbidities including hypertension, hyperlipidemia, diabetes mellitus, obesity, smoking, and family history of myocardial infarction. Results: In the 880 hospitalizations involving pre-op CKD and 2209 without CKD, no statistically significant differences were noted in in-hospital mortality, LOS or total charges (p>0.05) after adjusting for age and comorbidities. No significant trends were noted over the study period for in-hospital mortality, LOS, and cost for the two groups (p>0.05). Average cost of hospitalization was $852,745 and average LOS was 37 days. Patients
with CKD tended to be older (58.6 vs. 54.0 years) with a higher proportion of males (84% vs. 74%) and included more patients of African American race (29% vs. 21%). Patients with CKD also had a higher proportion of Medicare patients. There were no significant differences between the two groups in postoperative atrial fibrillation or stroke, or the post-procedural need for dialysis catheters or hemodialysis. Conclusions: CKD (Stage 1-4) did not have a significant impact on index LVAD implant hospitalization in terms of inpatient mortality, LOS, total charges, and postoperative complications.
440 Reversibility of Fixed Pulmonary Hypertension with LVADs as a Bridge to Candidacy Strategy for Heart Transplantation: A Systematic Review and MetaAnalysis Edgar E. Acuna-Morin1, Vanessa Blumer2, Manuel Rivera-Maza3, Veraprapas Kittipibul1, Jennifer Maning1, Sandra Chaparro1, Emer Joyce4; 1University of Miami, Miami, FL; 2Duke University, Durham, NC; 3Washington University, St. Louis, MO; 4 Mater Misericordiae University Hospital, Dublin, Ireland Introduction: Current guidelines recommend against listing for heart transplantation (HTx) if there is evidence of fixed pulmonary hypertension (fPH) given that these patients tend to have poor post-HTx outcomes. The purpose of this study is to investigate the feasibility of left ventricular assist device (LVAD) implantation as a bridge to candidacy (BTC) in patients with fPH through a systematic review and meta-analysis of published literature. Methods: We systematically searched Medline, Embase & the Cochrane library through December 31, 2018 for studies reporting patients with fPH treated with LVADs as a BTC for HTx. The primary outcome analyzed percentage of patients within each cohort achieving reversibility of pulmonary hemodynamics and the secondary endpoint was the time necessary to improve hemodynamics. Studies meeting inclusion criteria were assessed with the Newcastle-Ottawa tool. We performed a random-effects meta-analysis using pooled proportions and heterogeneity was examined using I2 statistics. All statistical analyses were carried out using Stata/IC 14.2. Results: A total of 8 studies (6 retrospective cohorts and 2 prospective cohorts) including 207 patients (89% male, mean age 49.46 years) formed part of our analysis. Continuous flow LVADs were used in 176 patients (79%). Our meta-analysis showed 97% reversal of fPH (95% CI, 88-100%) (Figure 1). The mean response time was of 5.33 months (95% CI: 3.67-7.00). Out of the initial 207 patients, 80% (95% CI:6198%) were effectively bridged to receive a HTx. Conclusions: Our findings show that in patients unable to be listed for HTx due to fPH, a BTC strategy with LVAD implantation is associated with improvement in pulmonary hemodynamics with a mean response time of approximately 5 months. Further studies evaluating longterm outcomes in these patients are warranted.
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Surgery/Transplantation/Devices 438 Trans-Caval Impella 5.0: A Bridge to Recovery in Peripartum Cardiomyopathy Waleed Al-Darzi, Alexander Michaels, William O’Neill, Celeste T. Williams; Henry Ford Hospital, Detroit, MI Introduction: The incidence of peripartum cardiomyopathy (PPCMP) varies worldwide, the etiology is thought to be related to both environmental and genetic factors. The mortality rates are reported up to 16.7% and transplant rates up to 11%. The Interagency Registry for Mechanically Assisted Circulatory Support demonstrated improved myocardial recovery in PPCMP patients compared to non-PPCMP patients (6% vs. 1%) who required durable mechanical circulatory support devices (MCS). Our case demonstrates the use of trans-caval Impella 5.0 as a bridge to recovery in a PPCMP patient with cardiogenic shock post delivery. Clinical Presentation: 37-year-old woman with a history of PPCMP presented with progressive shortness of breath during the third trimester of pregnancy. She was found to have a decrease in left ventricular ejection fraction (LVEF) to 30-35% at 30 weeks gestation. Right heart catheterization showed RA 12 mmHg, PA 75/38 (50) mmHg, PCWP 30 mmHg, and CI 1.99 L/min/m2. She was transferred to Cardiac Intensive Care Unit (CICU) for invasive hemodynamic monitoring and tailored therapy. Nitroprusside was started with up titration of oral afterload reduction medications and continued intravenous diuresis. Due to preeclampsia, labor induction was initiated during week 34 of gestation. Secondary to multiple decelerations on fetal monitoring, an emergent primary C-section with bilateral tubal ligation was performed. Immediately after delivery, patient suffered hemodynamic collapse requiring emergent placement of a right femoral 2.5L Impella; noting small ilio-femoral arteries on angiography. There was no significant hemodynamic improvement (low cardiac index, elevated PA pressure, and progressive hypotension); patient was emergently upgraded to an Impella 5.0 via trans-caval approach under transesophageal echocardiogram guidance. Patient experienced cardiac arrest during procedure, with immediate ROSC. The Impella 5.0 placement was successful without complications and with improvement in hemodynamics (Improved CI from 1.3 to 1.6 L/min/m2, MAP from 55 to 88 mmHg, cardiac power output from 0.29 to 0.42 W), pH from 7.02 to 7.30. The 2.5L Impella removal was complicated by a right iliac artery rupture requiring a covered stent placement. CICU course was complicated by retroperitoneal hematoma, and acute renal failure requiring hemodialysis. Impella 5.0 was removed four days later; a 12/10 mm amplatz ductal occluder was used to close the transcaval arteriotomy site. Hemodialysis was discontinued 12 days post-delivery and her LVEF improved to 40-45%. She was discharged to rehab and had significant improvement in her functional capacity on her 6-week follow up. Conclusion: Close monitoring and prompt action to escalate hemodynamic support, with temporary MCS to achieve better outcomes in cardiogenic shock is imperative. Transcaval Impella 5.0 is a feasible alternative to extracorporeal membrane oxygenation and provides a high level of hemodynamic support which could bridge to myocardial recovery in PPCMP patients suffering from cardiogenic shock.
439 Impact of Renal Dysfunction on Patients Undergoing Left Ventricular Assist Device Implantation Aasim Afzal, Tariq Nisar, Aayla Jamil, Aaron Kluger, Joost Felius, Timothy Gong, Shelley Hall, Parag Kale; Baylor University Medical Center, Dallas, TX Background: Left ventricular assist devices (LVADs) are increasingly used as a bridge to transplant or destination therapy. Renal dysfunction often precludes patients from single organ heart transplantation. However, the effect of preoperative renal dysfunction on LVAD outcomes is often debated, with limited literature available. Hypothesis: Patients with preoperative chronic kidney disease undergoing LVAD implantation have worse periprocedural outcomes. Methods: All hospitalizations of patients with systolic heart failure with index LVAD implantation (ICD-9 procedure code 37.66) were identified from the 2008-2014 National Inpatient Sample. Patients were stratified based on whether they had preoperative chronic kidney disease (CKD stage 1-4) (diagnosis codes 585.X) or normal renal function. Outcomes including in-hospital mortality, LOS, cost of care, and postoperative complications were analyzed. Trends over time were determined using the Cochran Armitage and Cuzick tests. Multivariate models were constructed with logistic and linear regression (gamma function) using the discharge weights provided under NIS guidelines. These models were adjusted for age and comorbidities including hypertension, hyperlipidemia, diabetes mellitus, obesity, smoking, and family history of myocardial infarction. Results: In the 880 hospitalizations involving pre-op CKD and 2209 without CKD, no statistically significant differences were noted in in-hospital mortality, LOS or total charges (p>0.05) after adjusting for age and comorbidities. No significant trends were noted over the study period for in-hospital mortality, LOS, and cost for the two groups (p>0.05). Average cost of hospitalization was $852,745 and average LOS was 37 days. Patients
with CKD tended to be older (58.6 vs. 54.0 years) with a higher proportion of males (84% vs. 74%) and included more patients of African American race (29% vs. 21%). Patients with CKD also had a higher proportion of Medicare patients. There were no significant differences between the two groups in postoperative atrial fibrillation or stroke, or the post-procedural need for dialysis catheters or hemodialysis. Conclusions: CKD (Stage 1-4) did not have a significant impact on index LVAD implant hospitalization in terms of inpatient mortality, LOS, total charges, and postoperative complications.
440 Reversibility of Fixed Pulmonary Hypertension with LVADs as a Bridge to Candidacy Strategy for Heart Transplantation: A Systematic Review and MetaAnalysis Edgar E. Acuna-Morin1, Vanessa Blumer2, Manuel Rivera-Maza3, Veraprapas Kittipibul1, Jennifer Maning1, Sandra Chaparro1, Emer Joyce4; 1University of Miami, Miami, FL; 2Duke University, Durham, NC; 3Washington University, St. Louis, MO; 4 Mater Misericordiae University Hospital, Dublin, Ireland Introduction: Current guidelines recommend against listing for heart transplantation (HTx) if there is evidence of fixed pulmonary hypertension (fPH) given that these patients tend to have poor post-HTx outcomes. The purpose of this study is to investigate the feasibility of left ventricular assist device (LVAD) implantation as a bridge to candidacy (BTC) in patients with fPH through a systematic review and meta-analysis of published literature. Methods: We systematically searched Medline, Embase & the Cochrane library through December 31, 2018 for studies reporting patients with fPH treated with LVADs as a BTC for HTx. The primary outcome analyzed percentage of patients within each cohort achieving reversibility of pulmonary hemodynamics and the secondary endpoint was the time necessary to improve hemodynamics. Studies meeting inclusion criteria were assessed with the Newcastle-Ottawa tool. We performed a random-effects meta-analysis using pooled proportions and heterogeneity was examined using I2 statistics. All statistical analyses were carried out using Stata/IC 14.2. Results: A total of 8 studies (6 retrospective cohorts and 2 prospective cohorts) including 207 patients (89% male, mean age 49.46 years) formed part of our analysis. Continuous flow LVADs were used in 176 patients (79%). Our meta-analysis showed 97% reversal of fPH (95% CI, 88-100%) (Figure 1). The mean response time was of 5.33 months (95% CI: 3.67-7.00). Out of the initial 207 patients, 80% (95% CI:6198%) were effectively bridged to receive a HTx. Conclusions: Our findings show that in patients unable to be listed for HTx due to fPH, a BTC strategy with LVAD implantation is associated with improvement in pulmonary hemodynamics with a mean response time of approximately 5 months. Further studies evaluating longterm outcomes in these patients are warranted.