- Email: [email protected]
Preoperative Moderate to Severe Tricuspid Regurgitation Does Not Affect Outcomes Following Placement of Continuous Flow LVADs
S116
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
At explantation (mean duration 249⫾209 days), gal-3 levels were significantly higher than at implantation (40.4⫾19 ng/ml vs. 29.2⫾14 ng/ ml; p¼0.005). Pre-implantation gal-3 levels predicted survival in patients on LVAD support (dichotomized at cut-off 30 ng/ml; log rank p¼0.03).
end-stage HF. It is possible that use of LVADs may allow myocardial recovery in the setting of novel pharmacologic or cell based interventions. 295 Preoperative Moderate to Severe Tricuspid Regurgitation Does Not Affect Outcomes Following Placement of Continuous Flow LVADs J.O. Robertson,1 S. Okada,1 S.M. Joseph,2 A. Itoh,1 G.A. Ewald,2 R.J. Damiano,1 S. Prasad,1 S.C. Silvestry.1 1Surgery (Division of Cardiothoracic Surgery), Washington University, St. Louis, MO; 2 Medicine (Division of Cardiology), Washington University, St. Louis, MO.
Conclusions: Gal-3 levels are associated with HF state and predict survival on LVAD support. Distinct dynamics in gal-3 levels occur in patients following LVAD implantation with an initial decrease but subsequent increase. Gal-3 may serve as a new biomarker for risk assessment of patients before LVAD implantation. 294 Changes in Left Ventricular Ejection Fraction Following Implantation of Left Ventricular Assist Device as Destination Therapy S.M. Dunlay,1 S.J. Park,2 K. Chandrasekaran,3 J.-O. Choi,2 N.L. Pereira,1 L.D. Joyce,2 R.C. Daly,2 J.M. Stulak,2 S.S. Kushwaha.1 1 Internal Medicine/ Cardiology, Mayo Clinic, Rochester, MN; 2 Cardiothoracic Surgery, Mayo Clinic, Rochester, MN; 3Cardiology/ Internal Medicine, Mayo Clinic, Scottsdale, AZ. Purpose: Recovery of left ventricular (LV) function has been reported following prolonged myocardial unloading with left ventricular assist device (LVAD) therapy. However, recovery appears to be limited to younger patients presenting acutely with non-ischemic heart failure (HF), and it is unclear how often LV recovery occurs after destination LVAD. Methods and Materials: Patients undergoing destination LVAD at the Mayo Clinic in Minnesota from April 2007 to February 2012 with at least 6 months of follow-up were included. Ejection fraction (EF) was obtained from transthoracic echocardiographic studies pre-LVAD and at 6 and 12 months post-LVAD. Use of beta blockers, ACE inhibitors, angiotensin-receptor blockers, and aldosterone antagonists at hospital dismissal were recorded. Patients were censored at death or last follow-up. Results: Among 69 patients (mean age 64 years, 16% female, 59% ischemic HF, 97% continuous-flow LVAD), the mean EF was 18% pre-LVAD, 23% 6 months post-LVAD, and 22% 12 months postLVAD. At 6 and 12 months post-LVAD, the EF increased by a mean of 5% and 4% compared with baseline, respectively (paired t-test p¼0.001). By one year post-LVAD, 13 (22%) patients had an increase in EF of Z10%, with greater improvements in those with lower preLVAD EF. The change in EF was similar in patients with ischemic (mean EF increase 3%) vs. nonischemic HF (mean EF increase 7%, p¼0.13). Use of HF medications had no impact on the change in EF. There were only 2 patients who had an improvement in EF to Z50% by 1 year. There was no association between change in EF at 6 months and subsequent mortality. Conclusions: In our experience, EF only improved slightly after destination LVAD, and rarely reached a normal range. This suggests that mechanical unloading alone is not the main mechanism for LV recovery in
Purpose: In patients undergoing LVAD implantation, preoperative tricuspid valve (TV) regurgitation (TR) may lead to prolonged hospital stay, early mortality and post-operative RV dysfunction necessitating RVAD implantation. However, the impact of preoperative TR on postoperative morbidity and mortality is unknown, and the decision to operate for TR is controversial. Methods and Materials: Between June 2005 and June 2012, 209 patients underwent implantation of continuous flow, implantable LVADs without concomitant TV repair. TR was Absent/Trivial or Mild in 57.9% (n¼121, Group 1) and moderate/severe in 42.1% (n¼88, Group 2). Outcomes were compared between groups using prospectively collected data from our institutional STS database. Results: Heartmate II LVADs were placed in 76.1% of patients. Groups 1 and 2 had similar percentages of patients who received an LVAD as bridge to transplant (66.9% vs. 75.3%) and destination therapy (32.2% vs. 28.4%). Preoperative moderate to severe impairment of the RVEF was seen more commonly in Group 2 (43.3% vs. 62.7%, p¼0.014), but this did not result in a higher rate of subsequent RVAD insertion (5.8% vs. 5.7%, p¼1.00). No differences were seen with respect to either 30-day (6.6% vs. 10.2%, p¼0.44) or overall (31.4% vs. 36.4%, p¼0.46) mortality. Postoperative renal failure, ICU length of stay and hospital length of stay was similar in both groups as well.
Conclusions: Preoperative evaluation of the severity of TR does not impact short term outcomes or RV morbidity and mortality, and it does not predict which patients would benefit from biventricular support. Further data regarding the long term effects of TR and the effect of TV repair or replacement are needed. 296 Meeting INR Targets for the Left Ventricular Assist Device Patient S.A. Schaefer, A.A. Schmitt, J. Bjelkengren, S. Lewey, B. McLaughlin, D. Sato, S. Puhlman, S. Pyo, R. Oberst, E.A. Lawrence, P.D. Hester, C. Sparks, P.J. Kaley, S. Blevins, D.D. Sandler, T.B. Icenogle. Inland Northwest Thoracic Organ Transplant Program, Providence Sacred Heart Medical Center, Spokane, WA. Purpose: Substantial time and effort is allocated to anticoagulation management for left ventricular assist device (LVAD) patients. The purpose of this retrospective study was to first determine how often patients from a single center’s FDA approved continuous flow LVAD patient population fall into their target INR range, and secondly to determine if those who experienced clotting and/or bleeding adverse events (Aes) had a significantly higher percentage of INR results outside of their target INR range in comparison to patients without such complications. Methods and Materials: Policy requires weekly INR checks for LVAD patients. Three INR ranges have been established for the patient population, based upon individual patient history of bleeding, clotting,
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
At explantation (mean duration 249⫾209 days), gal-3 levels were significantly higher than at implantation (40.4⫾19 ng/ml vs. 29.2⫾14 ng/ ml; p¼0.005). Pre-implantation gal-3 levels predicted survival in patients on LVAD support (dichotomized at cut-off 30 ng/ml; log rank p¼0.03).
end-stage HF. It is possible that use of LVADs may allow myocardial recovery in the setting of novel pharmacologic or cell based interventions. 295 Preoperative Moderate to Severe Tricuspid Regurgitation Does Not Affect Outcomes Following Placement of Continuous Flow LVADs J.O. Robertson,1 S. Okada,1 S.M. Joseph,2 A. Itoh,1 G.A. Ewald,2 R.J. Damiano,1 S. Prasad,1 S.C. Silvestry.1 1Surgery (Division of Cardiothoracic Surgery), Washington University, St. Louis, MO; 2 Medicine (Division of Cardiology), Washington University, St. Louis, MO.
Conclusions: Gal-3 levels are associated with HF state and predict survival on LVAD support. Distinct dynamics in gal-3 levels occur in patients following LVAD implantation with an initial decrease but subsequent increase. Gal-3 may serve as a new biomarker for risk assessment of patients before LVAD implantation. 294 Changes in Left Ventricular Ejection Fraction Following Implantation of Left Ventricular Assist Device as Destination Therapy S.M. Dunlay,1 S.J. Park,2 K. Chandrasekaran,3 J.-O. Choi,2 N.L. Pereira,1 L.D. Joyce,2 R.C. Daly,2 J.M. Stulak,2 S.S. Kushwaha.1 1 Internal Medicine/ Cardiology, Mayo Clinic, Rochester, MN; 2 Cardiothoracic Surgery, Mayo Clinic, Rochester, MN; 3Cardiology/ Internal Medicine, Mayo Clinic, Scottsdale, AZ. Purpose: Recovery of left ventricular (LV) function has been reported following prolonged myocardial unloading with left ventricular assist device (LVAD) therapy. However, recovery appears to be limited to younger patients presenting acutely with non-ischemic heart failure (HF), and it is unclear how often LV recovery occurs after destination LVAD. Methods and Materials: Patients undergoing destination LVAD at the Mayo Clinic in Minnesota from April 2007 to February 2012 with at least 6 months of follow-up were included. Ejection fraction (EF) was obtained from transthoracic echocardiographic studies pre-LVAD and at 6 and 12 months post-LVAD. Use of beta blockers, ACE inhibitors, angiotensin-receptor blockers, and aldosterone antagonists at hospital dismissal were recorded. Patients were censored at death or last follow-up. Results: Among 69 patients (mean age 64 years, 16% female, 59% ischemic HF, 97% continuous-flow LVAD), the mean EF was 18% pre-LVAD, 23% 6 months post-LVAD, and 22% 12 months postLVAD. At 6 and 12 months post-LVAD, the EF increased by a mean of 5% and 4% compared with baseline, respectively (paired t-test p¼0.001). By one year post-LVAD, 13 (22%) patients had an increase in EF of Z10%, with greater improvements in those with lower preLVAD EF. The change in EF was similar in patients with ischemic (mean EF increase 3%) vs. nonischemic HF (mean EF increase 7%, p¼0.13). Use of HF medications had no impact on the change in EF. There were only 2 patients who had an improvement in EF to Z50% by 1 year. There was no association between change in EF at 6 months and subsequent mortality. Conclusions: In our experience, EF only improved slightly after destination LVAD, and rarely reached a normal range. This suggests that mechanical unloading alone is not the main mechanism for LV recovery in
Purpose: In patients undergoing LVAD implantation, preoperative tricuspid valve (TV) regurgitation (TR) may lead to prolonged hospital stay, early mortality and post-operative RV dysfunction necessitating RVAD implantation. However, the impact of preoperative TR on postoperative morbidity and mortality is unknown, and the decision to operate for TR is controversial. Methods and Materials: Between June 2005 and June 2012, 209 patients underwent implantation of continuous flow, implantable LVADs without concomitant TV repair. TR was Absent/Trivial or Mild in 57.9% (n¼121, Group 1) and moderate/severe in 42.1% (n¼88, Group 2). Outcomes were compared between groups using prospectively collected data from our institutional STS database. Results: Heartmate II LVADs were placed in 76.1% of patients. Groups 1 and 2 had similar percentages of patients who received an LVAD as bridge to transplant (66.9% vs. 75.3%) and destination therapy (32.2% vs. 28.4%). Preoperative moderate to severe impairment of the RVEF was seen more commonly in Group 2 (43.3% vs. 62.7%, p¼0.014), but this did not result in a higher rate of subsequent RVAD insertion (5.8% vs. 5.7%, p¼1.00). No differences were seen with respect to either 30-day (6.6% vs. 10.2%, p¼0.44) or overall (31.4% vs. 36.4%, p¼0.46) mortality. Postoperative renal failure, ICU length of stay and hospital length of stay was similar in both groups as well.
Conclusions: Preoperative evaluation of the severity of TR does not impact short term outcomes or RV morbidity and mortality, and it does not predict which patients would benefit from biventricular support. Further data regarding the long term effects of TR and the effect of TV repair or replacement are needed. 296 Meeting INR Targets for the Left Ventricular Assist Device Patient S.A. Schaefer, A.A. Schmitt, J. Bjelkengren, S. Lewey, B. McLaughlin, D. Sato, S. Puhlman, S. Pyo, R. Oberst, E.A. Lawrence, P.D. Hester, C. Sparks, P.J. Kaley, S. Blevins, D.D. Sandler, T.B. Icenogle. Inland Northwest Thoracic Organ Transplant Program, Providence Sacred Heart Medical Center, Spokane, WA. Purpose: Substantial time and effort is allocated to anticoagulation management for left ventricular assist device (LVAD) patients. The purpose of this retrospective study was to first determine how often patients from a single center’s FDA approved continuous flow LVAD patient population fall into their target INR range, and secondly to determine if those who experienced clotting and/or bleeding adverse events (Aes) had a significantly higher percentage of INR results outside of their target INR range in comparison to patients without such complications. Methods and Materials: Policy requires weekly INR checks for LVAD patients. Three INR ranges have been established for the patient population, based upon individual patient history of bleeding, clotting,