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Managing patients with left ventricular assist device at home, results with 37 patient-years of experience
S206
Abstracts
405 NATRIURETIC PEPTIDES AS PREDICTORS OF CLINICAL COURSE IN PATIENTS WITH END-STAGE HEART FAILURE E.V. Potapov,1 F.D. Wagner,1 F.K. Hennig,1 C. Mu ¨ller,2 H. Lehmkuhl,1 R. Sodian,1 H. Hausmann,1 B.A. Nasseri,1 R. Hetzer,1 1Thoracic and Cardiovascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany; 2Clinical Chemistry, Charite´, Humboldt University, Berlin, Germany The optimal time-point for HTx or implantation of a VAD in patients with end-stage heart failure is a key issue. In 73 patients with heart failure requiring inotropic support blood was sampled daily and big endothelin-1 (big ET) and natriuretic peptides were measured at the end of the study. Clinical parameters were also evaluated daily. The patients were divided into groups with regard to the following endpoints: Group I - immediate VAD placement due to profound cardiogenic shock on admission (n⫽9); Group II - deterioration into cardiogenic shock after an initially stable clinical course (n⫽21); Group III - stable clinical course allowed urgent HTx or VAD implantation (n⫽35); Group IV - weaning from inotropic support (n⫽8). The parameters were evaluated as potential predictors for clinical course. On admission there were no significant predictors for the clinical course except lower ANP level in group IV compared to group II (p⫽0-005). Among the parameters evaluated, only BNP and big ET showed significant differences between groups II and III during follow up. BNP was elevated in group II compared to the group III three days, two days and one day before profound cardiogenic shock occurred (p⫽0.04; p⫽0.05; p⫽0.019 resp.). Big ET was elevated in group II only 1 day before profound cardiogenic shock occurred (p⫽0.02). ProBNP remained unchanged during treatment in groups II and III, but decreased significantly in group IV (p ⫽ 0.9, p ⫽ 0.6 and p ⫽ 0.025 resp.). While clinical parameters on admission did not predict the clinical course, lower ANP was found in patients weaned from inotropic support. A decrease of proBNP was also found in these patients. Elevated BNP indicated cardiogenic shock up to 3 days before its occurrence. Daily measurement of natriuretic peptides may be used for determination of optimal time-point for VAD implantation in patients with severe end-stage heart failure. 406 IMPROVED OVERALL OUTCOME WITH THE MICROMED DEBAKEY LVAD AS BRIDGE TO TRANSPLANT S. Salzberg, M. Lachat, A. Kadner, G. Zuend, M. Turina, Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland Objective: To evaluate the results obtained with the MicroMed DeBakey LVAD on overall outcome in end stage heart failure patients as bridge to recovery in view of heart transplantation (HTX). Methods: Prospective study, since October 1999, in 15 transplantation candidates (mean age 40⫾17 years) with end-stage heart failure and low-output syndrome due to coronary artery disease (n⫽5), cardiomyopathy (n⫽4), congenital (n⫽5) and valvular disease (n⫽1). Urgent implantation was necessary in eight. Procedure performed under normotherm femoro-femoral arterio-venous CPB in 14, ECMO in one. Beating heart in seven, ventricular fibrillation in the first eight as cardioprotection. Results: Successful implantation in all, weaning of inotropes and discharge from ICU (mean stay 10⫾7days) was possible in 11 patients. Seven patients underwent succesfull HTX (mean support 54⫾22 days), one is still awaiting a suitable donor organ (support 180 days). Four
The Journal of Heart and Lung Transplantation January 2003 early and three late deaths occurred. No device malfunctions during 893 patient support days. All survivors were discharged from hospital with significant decrease in NYHA class, treadmill testing showing increased exercise tolerance, decrease of BNP and normalization of pulmonary vascular resistance under LVAD support. Conclusions: The Micromed DeBakey LVAD is simple to implant, maintain and explant during HTX surgery. Patient’s improve their clinical state and PVR values normalize within 6 weeks, allowing for a low-risk environment for HTX, increasing donor-recipient matching and overall survival. 407 MANAGING PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICE AT HOME, RESULTS WITH 37 PATIENT-YEARS OF EXPERIENCE R. Khodaverdian, K.E. Nelson, B.L. Porter, A.J. Powers, T.F. Nielson, J.W. Long, Utah Artificial Heart Program, LDS Hospital, Salt Lake City, UT Background: Current technologies allow for the possibility of discharging patients on LVAD to their homes. LVAD outpatient management has become standard of care but yet faces challenges, which accrue with the duration of support. We reviewed our experience with these patients at home to assess the risks and benefits of an LVAD outpatient program. Methods: Our institutional experience with 43 patients on VE HeartMate LVADs (Thoratec) was analyzed. Results: Forty-three patients (35 males, 8 females) with mean age of 53 ⫹/- 15 years were discharged. The discharge rate in this group was 86% (43/50), with 36.5 pt-years at home. These patients spent 86% of their support time outside the hospital with the average of 310 days (range 5-1195 days) in the outpatient setting. Twenty-one patients (48%) were discharged to communities distant from the implanting center. Of these, 11 patients (26%) were in other states. Of the 30 patients who were implanted as a Bridge to Transplantation (BTT), 25 patients (83%) were successfully transplanted with no mortality. Median outpatient time in the BTT group was 107 days (range 5-1195). In the destination therapy group, 12 patients were followed for 6323 outpatient days with the median outpatient duration of 528 (range 42-1004). There were 7 deaths (58%) in this group with median survival of 2.1 years (95% C.I⫽1.1-3.1years). Adverse events happened at the average rate of 0.4 and 0.1 per 100 outpatient days in DT and BTT patients respectively. They also experienced a good quality of life with 16 (37%) traveling, 13 (30%) being able to drive with a controlled release program, and 8 (19%) getting back to a regular job. Conclusions: The HeartMate LVAD provides effective and reliable support for end-stage heart failure patients in the outpatient setting with remarkable quality of life and acceptable morbidity. This report is among the largest outpatient experience described. 408 MECHANICAL SUPPORT FOR ISOLATED RV FAILURE IN POST-CARDIOTOMY PATIENTS N. Moazami, M.K. Pasque, M.R. Moon, R.L. Herren, M.S. Bailey, J.S. Lawton, R.J. Damiano, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO Background: Acute right ventricular (RV) failure in the post-cardiotomy patient has a poor prognosis. We evaluated the operative outcomes of patients with isolated RV failure that required a right ventricular assist device (RVAD).
Abstracts
405 NATRIURETIC PEPTIDES AS PREDICTORS OF CLINICAL COURSE IN PATIENTS WITH END-STAGE HEART FAILURE E.V. Potapov,1 F.D. Wagner,1 F.K. Hennig,1 C. Mu ¨ller,2 H. Lehmkuhl,1 R. Sodian,1 H. Hausmann,1 B.A. Nasseri,1 R. Hetzer,1 1Thoracic and Cardiovascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany; 2Clinical Chemistry, Charite´, Humboldt University, Berlin, Germany The optimal time-point for HTx or implantation of a VAD in patients with end-stage heart failure is a key issue. In 73 patients with heart failure requiring inotropic support blood was sampled daily and big endothelin-1 (big ET) and natriuretic peptides were measured at the end of the study. Clinical parameters were also evaluated daily. The patients were divided into groups with regard to the following endpoints: Group I - immediate VAD placement due to profound cardiogenic shock on admission (n⫽9); Group II - deterioration into cardiogenic shock after an initially stable clinical course (n⫽21); Group III - stable clinical course allowed urgent HTx or VAD implantation (n⫽35); Group IV - weaning from inotropic support (n⫽8). The parameters were evaluated as potential predictors for clinical course. On admission there were no significant predictors for the clinical course except lower ANP level in group IV compared to group II (p⫽0-005). Among the parameters evaluated, only BNP and big ET showed significant differences between groups II and III during follow up. BNP was elevated in group II compared to the group III three days, two days and one day before profound cardiogenic shock occurred (p⫽0.04; p⫽0.05; p⫽0.019 resp.). Big ET was elevated in group II only 1 day before profound cardiogenic shock occurred (p⫽0.02). ProBNP remained unchanged during treatment in groups II and III, but decreased significantly in group IV (p ⫽ 0.9, p ⫽ 0.6 and p ⫽ 0.025 resp.). While clinical parameters on admission did not predict the clinical course, lower ANP was found in patients weaned from inotropic support. A decrease of proBNP was also found in these patients. Elevated BNP indicated cardiogenic shock up to 3 days before its occurrence. Daily measurement of natriuretic peptides may be used for determination of optimal time-point for VAD implantation in patients with severe end-stage heart failure. 406 IMPROVED OVERALL OUTCOME WITH THE MICROMED DEBAKEY LVAD AS BRIDGE TO TRANSPLANT S. Salzberg, M. Lachat, A. Kadner, G. Zuend, M. Turina, Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland Objective: To evaluate the results obtained with the MicroMed DeBakey LVAD on overall outcome in end stage heart failure patients as bridge to recovery in view of heart transplantation (HTX). Methods: Prospective study, since October 1999, in 15 transplantation candidates (mean age 40⫾17 years) with end-stage heart failure and low-output syndrome due to coronary artery disease (n⫽5), cardiomyopathy (n⫽4), congenital (n⫽5) and valvular disease (n⫽1). Urgent implantation was necessary in eight. Procedure performed under normotherm femoro-femoral arterio-venous CPB in 14, ECMO in one. Beating heart in seven, ventricular fibrillation in the first eight as cardioprotection. Results: Successful implantation in all, weaning of inotropes and discharge from ICU (mean stay 10⫾7days) was possible in 11 patients. Seven patients underwent succesfull HTX (mean support 54⫾22 days), one is still awaiting a suitable donor organ (support 180 days). Four
The Journal of Heart and Lung Transplantation January 2003 early and three late deaths occurred. No device malfunctions during 893 patient support days. All survivors were discharged from hospital with significant decrease in NYHA class, treadmill testing showing increased exercise tolerance, decrease of BNP and normalization of pulmonary vascular resistance under LVAD support. Conclusions: The Micromed DeBakey LVAD is simple to implant, maintain and explant during HTX surgery. Patient’s improve their clinical state and PVR values normalize within 6 weeks, allowing for a low-risk environment for HTX, increasing donor-recipient matching and overall survival. 407 MANAGING PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICE AT HOME, RESULTS WITH 37 PATIENT-YEARS OF EXPERIENCE R. Khodaverdian, K.E. Nelson, B.L. Porter, A.J. Powers, T.F. Nielson, J.W. Long, Utah Artificial Heart Program, LDS Hospital, Salt Lake City, UT Background: Current technologies allow for the possibility of discharging patients on LVAD to their homes. LVAD outpatient management has become standard of care but yet faces challenges, which accrue with the duration of support. We reviewed our experience with these patients at home to assess the risks and benefits of an LVAD outpatient program. Methods: Our institutional experience with 43 patients on VE HeartMate LVADs (Thoratec) was analyzed. Results: Forty-three patients (35 males, 8 females) with mean age of 53 ⫹/- 15 years were discharged. The discharge rate in this group was 86% (43/50), with 36.5 pt-years at home. These patients spent 86% of their support time outside the hospital with the average of 310 days (range 5-1195 days) in the outpatient setting. Twenty-one patients (48%) were discharged to communities distant from the implanting center. Of these, 11 patients (26%) were in other states. Of the 30 patients who were implanted as a Bridge to Transplantation (BTT), 25 patients (83%) were successfully transplanted with no mortality. Median outpatient time in the BTT group was 107 days (range 5-1195). In the destination therapy group, 12 patients were followed for 6323 outpatient days with the median outpatient duration of 528 (range 42-1004). There were 7 deaths (58%) in this group with median survival of 2.1 years (95% C.I⫽1.1-3.1years). Adverse events happened at the average rate of 0.4 and 0.1 per 100 outpatient days in DT and BTT patients respectively. They also experienced a good quality of life with 16 (37%) traveling, 13 (30%) being able to drive with a controlled release program, and 8 (19%) getting back to a regular job. Conclusions: The HeartMate LVAD provides effective and reliable support for end-stage heart failure patients in the outpatient setting with remarkable quality of life and acceptable morbidity. This report is among the largest outpatient experience described. 408 MECHANICAL SUPPORT FOR ISOLATED RV FAILURE IN POST-CARDIOTOMY PATIENTS N. Moazami, M.K. Pasque, M.R. Moon, R.L. Herren, M.S. Bailey, J.S. Lawton, R.J. Damiano, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO Background: Acute right ventricular (RV) failure in the post-cardiotomy patient has a poor prognosis. We evaluated the operative outcomes of patients with isolated RV failure that required a right ventricular assist device (RVAD).