Multidisciplinary Impact on Heart Failure Readmissions

The 23rd Annual Scientific Meeting  HFSA

S117

present a case of a patient with heart failure and CSA who underwent placement of a phrenic nerve stimulator and subsequently a left ventricular assist device (LVAD). Case: A 62 year-old male with NYHA III, ACC/AHA C heart failure (EF 15%), paroxysmal ventricular tachycardia with biventricular pacing and ICD placement who had polysomnography (PSG) that revealed severe CSA. He underwent placement of a transvenous phrenic nerve stimulation system. He subsequently reported improved symptoms, with less daytime sleeping and increased duration of daily exercise. His apnea hypopnea index decreased from 46.3 events/hour at baseline to 6.9 events/hour 18 months post-therapy, and his central apnea index decreased from 42.6 events/hour to 0.2 events/hour. Two years after device implant he underwent placement of an LVAD in the setting of worsening heart failure symptoms and refractory ventricular arrhythmias. Prior to surgery his device was placed in monitor mode. After successful LVAD implantation, despite normalization of cardiac output, he reported return of excessive daytime fatigue; PSG confirmed severe CSA. With device adjustment, the biventricular pacing leads, phrenic nerve stimulator system, and LVAD were able to run concurrently without artifact or interference. Subsequent PSG confirmed successful treatment of CSA along with improvement in symptoms. Discussion: CSA is common in patients with heart failure, thought to be related to elevated sympathetic nervous system activation and hemodynamic perturbations. Medical treatment of heart failure has shown limited success in improving CSA, and small studies have shown that optimization of hemodynamics and end-organ function with LVAD implantation does not reverse CSA. We report the first case of a patient with successful implantation of both a transvenous phrenic nerve stimulator and an LVAD. Despite normalization of cardiac output after LVAD implantation, severe CSA persisted, consistent with prior case reports. Conclusion: Phrenic nerve stimulation is an option for patients with heart failure and moderate to severe CSA, including LVAD patients.

Figure. A. Hyperpigmented Plaques with Well-defined Sharp Borders with Surrounding Hyperpigmentation and Central Thick Eschar (Right Posterior Leg). B. There is Unremarkable Squamous Epithelium at the Surface. C. Histopathology of Skin Punch Biopsy Demonstrates Characteristic Circumferential Calcifications of Several Small-10 Medium-sized Arteries and Afterioles in the Subcutaneous Tissue. D. Highlighted Calcium Special Stain.

316 Multidisciplinary Impact on Heart Failure Readmissions Sourin Banerji; Christiana Care Health System, Newark, DE

315 Phrenic Nerve Stimulation in an LVAD Patient with Severe Sleep Apnea Jenna Kay1, Timothy Meyer2, Robin Germany2, Lee Goldberg1; 1University of Pennsylvania, Philadelphia, PA; 2Respicardia, Minnetonka, MN Introduction: Central sleep apnea (CSA) occurs in approximately 35% of patients with heart failure, thought to be an acquired pattern of respiratory control instability related in part to elevated sympathetic nervous system activation. Studies show that CSA is an independent risk factor for morbidity and mortality in these patients. A newer approach to treatment involves implantation of a unilateral, transvenous phrenic nerve stimulator to restore a physiological breathing pattern during sleep. We

Introduction: HF related hospitalizations contribute significantly to health care costs. Consequently, the Hospitals Readmission Reduction Program (HRRP) was created to “support the national goal of improving health care for Americans by linking payment to quality of hospital care” including 30 day readmissions for HF hospitalizations. Many methods have been employed including patient centered (e.g. enhanced post-discharge monitoring) and non-patient centered (e.g. upcoding of disease severity) to reduce HF readmissions. Drivers of HF hospitalization vary and affect readmissions regardless of what patient centered or non-patient centered approaches are used. In this study, we used an inpatient multidisciplinary approach to find these drivers in patients at high risk for HF readmission and targeted these drivers in a specialized HF clinic. Hypothesis: Use of a multidisciplinary assessment of patients admitted with HF will reduce readmissions. Methods: Beginning Nov 2018,

S118 Journal of Cardiac Failure Vol. 25 No. 8S August 2019 6 patients (pts) were selected weekly using a health informatics database that identified pts admitted with HF. These pts were stratified by risk of readmission. They were included with the following criteria: presence of HF during hospitalization and modhigh risk of readmission. They were excluded for the following: ESRD requiring dialysis, severe COPD, advanced HF, location at ancillary site. These 6 pts were seen by the following entities: Supportive Palliative Care (SPC), Behavioral Health (BH), Physical Therapy and Cardiac Rehab, Pharmacy, a HF representative, and Case Management. A multidisciplinary meeting was held each Wednesday, and a focused discussion was held on the drivers of admission for HF. Issues pertinent to each pt were identified. Pts were discharged to a “bridge clinic” in which these issues were addressed with a) volume optimization using ReDS technology and an IV diuretic clinic, b) embedded BH/SPC, home PT as needed and a visiting nurse. Pts were seen weekly for 4 weeks and then followed with their Primary Physician or Cardiologist with continued management of issues identified in the multidisciplinary meeting. Readmission rate was followed subsequently. Results: 101 pts were selected between Nov 5th 2018 and Feb 25th 2019. These pts accounted for 183 HF related admissions in the 6 months prior to initiation of this program. Of these 101 pts, 17 were readmitted within 30 days of which 9 were HF related. This accounted for a readmission rate of 16.8% of our selected pts. The overall readmission rate for index HF hospitalizations during this time was 16.6%. Conclusions: Use of health informatics and a multidisciplinary team was associated with reduction in HF readmissions. Ongoing utilization of this program will be needed to assess whether this effect is persistent.

this case highlights the importance of careful patient selection and multidisciplinary decision-making for timing of LVAD implantation.

318 Acute Decompensated Congestive Heart Failure in a Heart Transplant Patient: Too Sugar, Too Bad Mohamad Khaled Soufi1, Karen M. Kislingbury2, Wissam I. Khalife1; 1Advanced Heart Failure and Transplant Cardiology, University of Texas Medical Branch, Galveston, TX; 2Texas Transplant Center, University of Texas Medical Branch, Galveston, TX Introduction: Diabetic cardiomyopathy (CMP) is an under-recognized type of CHF with a prevalence of 1.1%. Heart transplantation (HT) patients are at risk of developing de novo or worsening diabetes mellitus (DM) secondary to their immunosuppressive therapy. Thus, they are at risk of having diabetic CMP. We present a case of a patient with HT who presented with acute decompensated CHF (ADCHF) secondary to uncontrolled DM. Case: A 43-year-old male with a medical history of ischemic cardiomyopathy (EF of 5-10%) status post HT [EF of 50-55% with normal right ventricular (RV) function via TTE 6 months ago], DM type II, CKD stage III who presented with progressive shortness of breath and leg swelling. His immunosuppressive therapy included tacrolimus, mycophenolate mofetil, and prednisone. Labs showed BNP of 30000 pg/mL, Cr 2.1 mg/dL, blood glucose > 600 mg/dL, and Hb A1C 14. TTE showed a significant reduction in EF to 5-10% with moderate to severe RV dysfunction. The patient was started on milrinone infusion, insulin infusion, and IV diuresis. Left heart cath (LHC) showed mild luminal irregularities without significant coronary stenoses. Right heart cath (RHC) on milrinone showed RA 23, RV 50/11, PA 54/32, PCWP 29 mmHg, CO 4.2 L/min, CI 2.1 L/min/m2. Endomyocardial biopsy (EMB) revealed no acute cellular or humoral rejection. The patient was diagnosed with ADCHF secondary to diabetic CMP secondary to uncontrolled DM. He improved clinically during his hospital stay. His insulin regimen was adjusted and he was discharged to follow up with HF and Endocrinology. Discussion: In our patient, the initial diagnostic work-up (LHC, RHC, and EMB) aimed to investigate cardiac allograft vasculopathy and acute allograft rejection, the two most common causes of ADCHF in HT patients. However, after excluding these conditions, patient’s poorly controlled DM with HbA1C of 14 led to diagnosing him diabetic CMP. During the follow-up period, patient’s DM became under better control with Hb A1C of 6-7 which resulted in an improvement in his EF to 30-40% (after 4 months) and to 50-55% (after 7 months). Figure 1 demonstrates the fluctuation of patient’s ejection fraction before and after his HT along with his highest Hb A1C levels. As shown, periods of poorly controlled DM were associated with lower EF. Conclusion: Diabetic CMP is an under-recognized type of CHF. It is a diagnosis of exclusion that requires a low threshold of suspicion. As demonstrated in our case, attaining better DM control in patients with diabetic CMP results in an improvement in their cardiac function.

317 Timing of LVAD Implantation: A Case Report Steven F. Sorci1, Robby Wu1, Debbie Rinde-Hoffman2; 1Northside Hospital, St. Petersburg, FL; 2USF Morsani College of Medicine/Tampa General Hospital, Tampa, FL Optimal timing of left ventricular assist device (LVAD) implantation in critically ill patients remains uncertain. Multiple studies have demonstrated that implantation of LVADs in hemodynamically stable patients with preserved end-organ function leads to better outcomes. Although seemingly intuitive, this concept highlights the importance of patient selection and the optimal timing of LVAD implantation in critically ill patients. A 35 year-old gentleman with a past medical history of morbid obesity and alcohol abuse presented from an outside hospital. He was initially diagnosed with a cardiomyopathy eight years prior to admission, although demonstrated recovery of his left ventricular ejection fraction (LVEF) after guideline directed medical therapy. He subsequently stopped his medications five years prior to admission and had been doing well. He initially presented to the other institution with shortness of breath and progressive dyspnea on exertion. A cardiac catheterization was performed and demonstrated nonobstructive coronary artery disease. An echocardiogram demonstrated severe biventricular failure with an estimated LVEF of 10%, severe mitral regurgitation and an elevated RVSP of 40%. An Impella 3.5 was placed and the patient was aggressively diuresed. Despite ongoing management, the patient developed multiorgan failure with a peak total bilirubin of 65.5 mg/dL and a creatinine of 4.27 mg/dL. He was transferred to our institution for advanced therapy. Given his morbid obesity and findings of progressively worsening multi-organ failure, immediate surgical intervention was deferred. With placement of an Impella 5 and continued aggressive medical management, he made daily improvement. Multiple selection committee discussions were held regarding the optimal timing of intervention on the previously healthy 35 year old gentleman. Temporary LVAD support with the Impella 5 was maintained for a total of 5 weeks while his respiratory, renal, liver and nutritional function were addressed. The patient was found with significant azotemia and anuria which ultimately improved with supportive medical care and continuous renal replacement therapy. Prior to LVAD implantation, CRRT was no longer required. A HeartMate 3 was ultimately implanted on day 42 of his hospitalization and the patient continued to make excellent progress in recovery. It is unclear what led to the patient’s decline in cardiac function, although his morbid obesity, continued alcohol use and cessation of medical therapy likely all contributed. It Is impossible to determine whether earlier intervention would have changed his outcome. Regardless,

Figure 1. Demonstrates Patient’s Ejection Fraction (EF) over Time. Periods of High Hb A1C are Illustrated (Shaded in Yellow) Resulting in Lower EF. Acute Cellular Rejection Episodes are Illustrated as Well.

319 Medical Therapy Optimization of Advanced Heart Failure in a Cancer Patient: When to Quit? Mohamad Khaled Soufi1, Trudy H. Chang2, Khaled F. Chatila1; 1Advanced Heart Failure and Transplant Cardiology, University of Texas Medical Branch, Galveston, TX; 2 Department of Cardiology, University of Texas Medical Branch, Galveston, TX