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Resolution of Right Atrial Congestion before LVAD Implantation is Associated with Improved Outcomes
Abstracts returning back to their communities. The aim of this study was to investigate the impact of patient’s residential distance from the MCD implantation center on the rate of major complications, clinical outcomes and survival. Methods: 215 patients were implanted with continuous flow LVAD between June 2006 and September 2018 at our institution. Major LVAD complications (stroke, infection, right heart failure, gastrointestinal bleeding), hospitalization, and death were recorded. Patient’s residential distance from the MCD implantation center was determined. Patients were divided into 2 groups: patients living less than 100 miles (Group 1) and patients living greater than 100 miles away (Group 2). End points for follow up were met when the patient was transplanted or expired. Results: One hundred six patients resided in Group 1 (range 5-100 miles) and one hundred eight resided in Group 2 (range 100-1000 miles). Mean length of stay for patients in group 1 was 19§10 days versus 17 § 11 in group 2 patients (p=0.22). Major post-op complications included gastrointestinal bleeding (15% in Group 1 vs. 8% in Group 2), driveline infections (9% in Group 1 vs. 8% in Group 2), and infections not-related to LVAD (14% in Group 1 vs. 20% in Group 2). There was no statistical difference in post-operative complications, readmissions, or long term survival between patients staying near and far from the implant center. Conclusion: Distance of patient residence had no effect on clinical outcome, including complications or death, in our retrospective study on all patients on LVAD support at our institution. Distance is not a contraindication for MCD therapy. 1159 Resolution of Right Atrial Congestion before LVAD Implantation is Associated with Improved Outcomes G. Gulati,1 N. Sutaria,1 A. Vest,1 D. DeNofrio,1 M. Kawabori,2 G. Couper,2 and M. Kiernan.1 1Cardiology, Tufts Medical Center, Boston, MA; and the 2Cardiac Surgery, Tufts Medical Center, Boston, MA. Purpose: Increased right atrial pressure is known to be a predictor of poor outcomes after LVAD implantation. Whether resolution of right heart congestion prior to LVAD implantation is associated with more favorable outcomes is not well understood. Methods: We analyzed LVAD recipients from our institution from 1/1/ 2015 to 2/28/2018. We excluded patients bridged to LVAD with ECMO support. Patients with admission right atrial pressure (RAPadmit) and implant RAP (RAPimplant) ≥ 14 mmHg were defined as having persistent congestion, while patients with RAPadmit ≥ 14 mmHg and RAPimplant < 14 mmHg were defined as having resolved congestion. Baseline characteristics between groups were compared using the Chi-square and unpaired ttests. Time to death or RVAD was compared between groups using Cox proportional hazards models.
S459 Results: Of 57 LVAD recipients with RAPadmit ≥ 14 mmHg, 14 (25%) had persistent congestion at the time of LVAD implantation. While there were no statistically significant differences between groups, patients with persistent congestion were more likely to be INTERMACS profile 1 (21.4% vs 9.5%), less likely to have a destination therapy device strategy (28.6% vs 34.9%), less likely to have moderate or severe right ventricular (RV) dysfunction (64.3% vs 83.7%), and had similar RAPadmit (20.4 mmHg vs 18.9 mmHg) compared to patients with resolved congestion. Median follow up was 307 days. Patients with persistent congestion had a higher frequency of death or RVAD implantation compared to those with resolved congestion (50% vs 14%, HR 3.75, 95% CI 1.25-11.25, p=0.02, Figure). Conclusion: Among patients with elevated RAP at admission, patients with persistently elevated RAP at the time of LVAD implantation had worse outcomes than patients who were able to be decongested prior to surgery. These data support optimization of RV filling pressures prior to LVAD surgery.
1160 Cardiac CT Provides Complementary Parameters of Right Ventricle Function in LVAD Patients A. Scott, P.J. Kim, H. Tran, M. Brambatti, Y. Ignatyeva, S. Rosenberg, S. Kligerman, A. Hsiao, V. Pretorius, E. Adler and F. Contijoch. University of California, San Diego, San Diego, CA. Purpose: Patients receiving LVADs are at risk for post-operative right ventricular (RV) failure. Cardiac CT angiography (CTA) provides 3D isotropic spatial resolution and blood pool-myocardial delineation and can be used to assess ventricular volumes. We sought to evaluate whether right heart catheterization (RHC) and echocardiographic (echo) parameters of RV structure and function correlate with CT-derived parameters - specifically, RV ejection fraction RVEF, RV stroke volume index RVSVI, RV to LV end diastolic ratio RV-LVEDR, and RV end diastolic volume index RVEDVI. Methods: 11 LVAD candidates (age 55 § 12, 10 males) underwent cardiac CTA between 9/27/2017 and 10/16/2018. All patients had contemporaneous (within 7 days) echo examinations and 7 patients had contemporaneous RHCs. Pulmonary artery pulsatility index PAPI, RV stroke work index RVSWI, and the ratio of right atrial to pulmonary capillary wedge pressure RAP/PCWP were obtained from RHC reports and RV size, global function, and tricuspid annular plane systolic excursion (TAPSE) were obtained from echo reports. Ventricle size was graded as small, normal, mild, moderate, or severely enlarged, and ventricle function as normal or depressed. Pearson’s correlation coefficient (r) was calculated for each relationship. For echo-derived ventricular function, an unpaired t-test (p<0.05) was performed. Results: Structurally, echo derived RV size correlated moderately with CT RV EDVI and RAP/PCWP correlated strongly with RV-LVEDR. Functionally, RV SWI correlated well with RV EF and RV SVI. PAPI poorly correlated to RV EF and RV SVI. Echo-based characterization of global RV function was not associated with any CT-derived measures (p > 0.1). Conclusion: CT-derived RV parameters may provide complementary information to hemodynamic and echo assessment, especially RAP/PCWP and 2D echo parameters, and when combined could lead to comprehensive assessment of RV function. Further research is required to examine the relationship between TAPSE and RV EF.
Pearson Correlation between CT and RHC and Echo Derived Parameters RV EF RV SVI RV-LVEDR RV SWI (n=7) RAP/PCWP (n=7) PAPI (n=7) TAPSE (n=11) RV Size (n=11)
¡0.456 0.083 ¡0.076 ¡0.19 ¡0.459
¡0.622 0.219 ¡0.336 ¡0.573 ¡0.088
¡0.485 0.720 ¡0.577 0.084 0.726
RV EDVI 0.200 0.058 ¡0.253 ¡0.100 0.451
S459 Results: Of 57 LVAD recipients with RAPadmit ≥ 14 mmHg, 14 (25%) had persistent congestion at the time of LVAD implantation. While there were no statistically significant differences between groups, patients with persistent congestion were more likely to be INTERMACS profile 1 (21.4% vs 9.5%), less likely to have a destination therapy device strategy (28.6% vs 34.9%), less likely to have moderate or severe right ventricular (RV) dysfunction (64.3% vs 83.7%), and had similar RAPadmit (20.4 mmHg vs 18.9 mmHg) compared to patients with resolved congestion. Median follow up was 307 days. Patients with persistent congestion had a higher frequency of death or RVAD implantation compared to those with resolved congestion (50% vs 14%, HR 3.75, 95% CI 1.25-11.25, p=0.02, Figure). Conclusion: Among patients with elevated RAP at admission, patients with persistently elevated RAP at the time of LVAD implantation had worse outcomes than patients who were able to be decongested prior to surgery. These data support optimization of RV filling pressures prior to LVAD surgery.
1160 Cardiac CT Provides Complementary Parameters of Right Ventricle Function in LVAD Patients A. Scott, P.J. Kim, H. Tran, M. Brambatti, Y. Ignatyeva, S. Rosenberg, S. Kligerman, A. Hsiao, V. Pretorius, E. Adler and F. Contijoch. University of California, San Diego, San Diego, CA. Purpose: Patients receiving LVADs are at risk for post-operative right ventricular (RV) failure. Cardiac CT angiography (CTA) provides 3D isotropic spatial resolution and blood pool-myocardial delineation and can be used to assess ventricular volumes. We sought to evaluate whether right heart catheterization (RHC) and echocardiographic (echo) parameters of RV structure and function correlate with CT-derived parameters - specifically, RV ejection fraction RVEF, RV stroke volume index RVSVI, RV to LV end diastolic ratio RV-LVEDR, and RV end diastolic volume index RVEDVI. Methods: 11 LVAD candidates (age 55 § 12, 10 males) underwent cardiac CTA between 9/27/2017 and 10/16/2018. All patients had contemporaneous (within 7 days) echo examinations and 7 patients had contemporaneous RHCs. Pulmonary artery pulsatility index PAPI, RV stroke work index RVSWI, and the ratio of right atrial to pulmonary capillary wedge pressure RAP/PCWP were obtained from RHC reports and RV size, global function, and tricuspid annular plane systolic excursion (TAPSE) were obtained from echo reports. Ventricle size was graded as small, normal, mild, moderate, or severely enlarged, and ventricle function as normal or depressed. Pearson’s correlation coefficient (r) was calculated for each relationship. For echo-derived ventricular function, an unpaired t-test (p<0.05) was performed. Results: Structurally, echo derived RV size correlated moderately with CT RV EDVI and RAP/PCWP correlated strongly with RV-LVEDR. Functionally, RV SWI correlated well with RV EF and RV SVI. PAPI poorly correlated to RV EF and RV SVI. Echo-based characterization of global RV function was not associated with any CT-derived measures (p > 0.1). Conclusion: CT-derived RV parameters may provide complementary information to hemodynamic and echo assessment, especially RAP/PCWP and 2D echo parameters, and when combined could lead to comprehensive assessment of RV function. Further research is required to examine the relationship between TAPSE and RV EF.
Pearson Correlation between CT and RHC and Echo Derived Parameters RV EF RV SVI RV-LVEDR RV SWI (n=7) RAP/PCWP (n=7) PAPI (n=7) TAPSE (n=11) RV Size (n=11)
¡0.456 0.083 ¡0.076 ¡0.19 ¡0.459
¡0.622 0.219 ¡0.336 ¡0.573 ¡0.088
¡0.485 0.720 ¡0.577 0.084 0.726
RV EDVI 0.200 0.058 ¡0.253 ¡0.100 0.451