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Invasive Hemodynamic Testing in Ambulatory Left Ventricular Assist Device Patients
S390
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
a median follow up time of 780 days (2.1 years) from implantation to analysis. From ramp to analysis, there were 85 admissions, 29 of which were for heart failure exacerbations during a median follow up time of 274 days (0.75 years), yielding a heart failure re-hospitalization rate of 0.73 hospitalizations per patient year. Conclusion: Hemodynamic ramps are utilized to tailor an individual’s LVAD speeds to intra-cardiac filling pressures, cardiac indices and aortic valve opening. We found that compared to prior cohort studies, incorporating hemodynamic ramp testing results in favorable survival and heart failure readmission rates. 1( 091) Specialized Heart Clinic Versus Standard Anticoagulation Clinic Warfarin Management in Patients with Left Ventricular Assist Devices A. McCarty , S. Lee, P. de Voest, J. McDermott. Spectrum Health, Grand Rapids, MI. Purpose: Patients with left ventricular assist devices (LVAD) are at risk for thrombotic and bleeding complications necessitating careful warfarin management. In March 2015, warfarin management was transferred from a standard anticoagulation clinic to the specialized heart clinic where patients receive routine post-LVAD care. The purpose is to compare warfarin management in LVAD patients before and after transfer of care. Methods: A single-center retrospective study was conducted comparing patients that received a continuous flow (CF)-LVAD between Jan 1, 2014 and Dec 31, 2014 and were managed by a standard anticoagulation clinic (n= 30) vs. patients that received a CF-LVAD between March 1, 2015 to Sep 1, 2015 and were managed by the specialized heart clinic (n= 30). Readmissions within 90 days post-LVAD implant were reviewed and adverse events were recorded according to INTERMACS definitions. Patients that died during initial hospital stay or remain hospitalized post-LVAD implantation were excluded. Results: Select patient characteristics are listed in Table 1. Eighteen readmissions occurred in 13 patients (43%) managed by the standard anticoagulation clinic vs. 22 readmissions in 16 patients (53%) managed by the specialized heart clinic, p= 0.61. There were no significant differences in readmission adverse events between groups, although numerically more bleeding events were observed in patients managed by the standard anticoagulation clinic (Table 1). INR> 4 at any time 90 days post-LVAD implantation occurred more frequently in patients managed by the standard anticoagulation clinic, 19 (63.3%) versus 10 (33.3%), p= 0.04. Conclusion: LVAD patients experienced significantly less supratherapeutic INR values and no GI bleeding events when managed by a specialized heart clinic rather than a standard anticoagulation clinic. Anticoagulation management in the same clinic as other routine LVAD care allows for closer surveillance and intervention.
1( 092) Invasive Hemodynamic Testing in Ambulatory Left Ventricular Assist Device Patients N. Badoe , K. Abdullah, S. Phillips, J. Nabut, A.J. Rongione, S.S. Desai, P. Shah. Inova Heart and Vascular Institute, Falls Church, VA. Purpose: LVAD speed selection occurs in the operating room or peri-operative period when the patients are still recovering from surgery. The efficacy of this strategy in reversing the hemodynamic abnormalities of heart failure are poorly described. We sought to evaluate the degree of persistent heart failure after LVAD implant and assess the relationship of persistent hemodynamic abnormalities to LVAD complications.
Methods: Using our institutional LVAD registry, we queried 105 patients who had a right heart catheterization (RHC) performed > 30 days post-implant. We classified LVAD patient hemodynamics according to the Forrester Classification (FC) and assessed clinical outcomes based on hemodynamic categories. Our primary composite outcome was freedom from death, stroke, infection, device thrombosis and gastrointestinal bleeding. Results: Hemodynamics improved after LVAD implantation, the mean cardiac index rose from 1.9 ± 0.5 L/min/m² to 2.6 ± 0.5 L/min/m² and pulmonary capillary wedge pressure from 23 ± 9 mmHg to 13 ± 6 mmHg, p = 0.001 for both comparisons. After LVAD implant 42 patients (40%) were categorized into an abnormal hemodynamic group based on the FC (Figure A). Ramp testing with speed adjustment was performed in 38 patients (90%) to optimize hemodynamics. Hemodynamic optimization (i.e. warm/dry category) was achieved in 52% of ramped patients (p = 0.002 for pre- and post-ramp study). The composite endpoint showed no differences in the time to event (p = 0.64, Figure B). Conclusion: Current strategies for LVAD optimization may leave patients with persistent hemodynamic abnormalities which typify heart failure. Ramping with invasive hemodynamics may be beneficial for restoring normal hemodynamics. This strategy was associated with improved hemodynamics. The efficacy of this strategy in improving quality of life, functional status and readmission for right heart failure need to be evaluated further.
1( 093) Inpatient Rehabilitation of Biventricular Support Patients - A Special Challenge N. Reiss ,1 E. Deniz,2 S. Jan,2 D. Willemsen.1 1Schuechtermann Clinic Bad Rothenfelde, Bad Rothenfelde, Germany; 2Medical School Hannover, Hannover, Germany. Purpose: 10-20% of VAD candidates still cannot be treated with an LVAD alone. Implantation of biventricular support systems - planned or unplanned - remains more challenging with lower survival, offers limited quality of life and may be proposed as bridge to transplant. The aim of this study was to characterize the clinical course and the physical capacity of BVAD patients during phase-II-rehabilitation (CR). Methods: Eight patients (4 male, 4 female, mean age 49.5 year) were admitted after a mean interval of 91 days after HeartWare BVAD implantation for CR. In three patients right ventricular support system was implanted later in non-expected severe right heart failure. Results: The clinical course after implantation was burdened with major complications (renal insufficiency n= 5, liver insufficiency n= 2, long-term ventilation n= 4, rethoracotomy n= 4, ECMO implantation n= 1, severe necrosis D II-V hand). All patients presented markedly reduced physical condition and extreme muscular deconditioning at the time of admission. Mean duration of CR was 38 days. All patients underwent individualised resistance and exercise training units (5-7 times/week). The 6-minute walk test distance improved significantly from 226 m to 333 m (p< 0.001) during CR. The maximal isometric strength of the M. quadriceps femoris also improved significantly (293 Nm vs.399 Nm; p< 0.001). Values were significantly lower than those of a corresponding LVAD control group. Conclusion: Rehabilitation of BVAD patients represents a special challenge because of prolonged hospital stay with numerous complications and severe muscular deconditioning esp. in cases of unplanned later right ventricular device implantation. Both, 6-MWT distance as a parameter for functional capacity and evaluation of MQF peak torque as a parameter for maximal strength could be improved significantly in BVAD patients, nevertheless values were lower than in a LVAD control group. The size
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
a median follow up time of 780 days (2.1 years) from implantation to analysis. From ramp to analysis, there were 85 admissions, 29 of which were for heart failure exacerbations during a median follow up time of 274 days (0.75 years), yielding a heart failure re-hospitalization rate of 0.73 hospitalizations per patient year. Conclusion: Hemodynamic ramps are utilized to tailor an individual’s LVAD speeds to intra-cardiac filling pressures, cardiac indices and aortic valve opening. We found that compared to prior cohort studies, incorporating hemodynamic ramp testing results in favorable survival and heart failure readmission rates. 1( 091) Specialized Heart Clinic Versus Standard Anticoagulation Clinic Warfarin Management in Patients with Left Ventricular Assist Devices A. McCarty , S. Lee, P. de Voest, J. McDermott. Spectrum Health, Grand Rapids, MI. Purpose: Patients with left ventricular assist devices (LVAD) are at risk for thrombotic and bleeding complications necessitating careful warfarin management. In March 2015, warfarin management was transferred from a standard anticoagulation clinic to the specialized heart clinic where patients receive routine post-LVAD care. The purpose is to compare warfarin management in LVAD patients before and after transfer of care. Methods: A single-center retrospective study was conducted comparing patients that received a continuous flow (CF)-LVAD between Jan 1, 2014 and Dec 31, 2014 and were managed by a standard anticoagulation clinic (n= 30) vs. patients that received a CF-LVAD between March 1, 2015 to Sep 1, 2015 and were managed by the specialized heart clinic (n= 30). Readmissions within 90 days post-LVAD implant were reviewed and adverse events were recorded according to INTERMACS definitions. Patients that died during initial hospital stay or remain hospitalized post-LVAD implantation were excluded. Results: Select patient characteristics are listed in Table 1. Eighteen readmissions occurred in 13 patients (43%) managed by the standard anticoagulation clinic vs. 22 readmissions in 16 patients (53%) managed by the specialized heart clinic, p= 0.61. There were no significant differences in readmission adverse events between groups, although numerically more bleeding events were observed in patients managed by the standard anticoagulation clinic (Table 1). INR> 4 at any time 90 days post-LVAD implantation occurred more frequently in patients managed by the standard anticoagulation clinic, 19 (63.3%) versus 10 (33.3%), p= 0.04. Conclusion: LVAD patients experienced significantly less supratherapeutic INR values and no GI bleeding events when managed by a specialized heart clinic rather than a standard anticoagulation clinic. Anticoagulation management in the same clinic as other routine LVAD care allows for closer surveillance and intervention.
1( 092) Invasive Hemodynamic Testing in Ambulatory Left Ventricular Assist Device Patients N. Badoe , K. Abdullah, S. Phillips, J. Nabut, A.J. Rongione, S.S. Desai, P. Shah. Inova Heart and Vascular Institute, Falls Church, VA. Purpose: LVAD speed selection occurs in the operating room or peri-operative period when the patients are still recovering from surgery. The efficacy of this strategy in reversing the hemodynamic abnormalities of heart failure are poorly described. We sought to evaluate the degree of persistent heart failure after LVAD implant and assess the relationship of persistent hemodynamic abnormalities to LVAD complications.
Methods: Using our institutional LVAD registry, we queried 105 patients who had a right heart catheterization (RHC) performed > 30 days post-implant. We classified LVAD patient hemodynamics according to the Forrester Classification (FC) and assessed clinical outcomes based on hemodynamic categories. Our primary composite outcome was freedom from death, stroke, infection, device thrombosis and gastrointestinal bleeding. Results: Hemodynamics improved after LVAD implantation, the mean cardiac index rose from 1.9 ± 0.5 L/min/m² to 2.6 ± 0.5 L/min/m² and pulmonary capillary wedge pressure from 23 ± 9 mmHg to 13 ± 6 mmHg, p = 0.001 for both comparisons. After LVAD implant 42 patients (40%) were categorized into an abnormal hemodynamic group based on the FC (Figure A). Ramp testing with speed adjustment was performed in 38 patients (90%) to optimize hemodynamics. Hemodynamic optimization (i.e. warm/dry category) was achieved in 52% of ramped patients (p = 0.002 for pre- and post-ramp study). The composite endpoint showed no differences in the time to event (p = 0.64, Figure B). Conclusion: Current strategies for LVAD optimization may leave patients with persistent hemodynamic abnormalities which typify heart failure. Ramping with invasive hemodynamics may be beneficial for restoring normal hemodynamics. This strategy was associated with improved hemodynamics. The efficacy of this strategy in improving quality of life, functional status and readmission for right heart failure need to be evaluated further.
1( 093) Inpatient Rehabilitation of Biventricular Support Patients - A Special Challenge N. Reiss ,1 E. Deniz,2 S. Jan,2 D. Willemsen.1 1Schuechtermann Clinic Bad Rothenfelde, Bad Rothenfelde, Germany; 2Medical School Hannover, Hannover, Germany. Purpose: 10-20% of VAD candidates still cannot be treated with an LVAD alone. Implantation of biventricular support systems - planned or unplanned - remains more challenging with lower survival, offers limited quality of life and may be proposed as bridge to transplant. The aim of this study was to characterize the clinical course and the physical capacity of BVAD patients during phase-II-rehabilitation (CR). Methods: Eight patients (4 male, 4 female, mean age 49.5 year) were admitted after a mean interval of 91 days after HeartWare BVAD implantation for CR. In three patients right ventricular support system was implanted later in non-expected severe right heart failure. Results: The clinical course after implantation was burdened with major complications (renal insufficiency n= 5, liver insufficiency n= 2, long-term ventilation n= 4, rethoracotomy n= 4, ECMO implantation n= 1, severe necrosis D II-V hand). All patients presented markedly reduced physical condition and extreme muscular deconditioning at the time of admission. Mean duration of CR was 38 days. All patients underwent individualised resistance and exercise training units (5-7 times/week). The 6-minute walk test distance improved significantly from 226 m to 333 m (p< 0.001) during CR. The maximal isometric strength of the M. quadriceps femoris also improved significantly (293 Nm vs.399 Nm; p< 0.001). Values were significantly lower than those of a corresponding LVAD control group. Conclusion: Rehabilitation of BVAD patients represents a special challenge because of prolonged hospital stay with numerous complications and severe muscular deconditioning esp. in cases of unplanned later right ventricular device implantation. Both, 6-MWT distance as a parameter for functional capacity and evaluation of MQF peak torque as a parameter for maximal strength could be improved significantly in BVAD patients, nevertheless values were lower than in a LVAD control group. The size