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Resource Utilization in HeartMate II Left Ventricular Assist Device Patients With Gastrointestinal Bleeding
The 16th Annual Scientific Meeting
HFSA
S45
145 An Aggressive, Targeted Perioperative Management Strategy Results in Low Rates of Postoperative Right Ventricular Failure After Left Ventricular Assist Device Implantation Amresh Raina, Manreet Kanwar, George Sokos, Robert Moraca, Stephen Bailey, Raymond L. Benza, Srinivas Murali; Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA
mean BP at presentation, require more red cell transfusions and have a higher rate or recurrent bleeding compared to those with non-AVM bleeding. However, mortality at 3 year follow-up is comparable in both groups.
144 Resource Utilization in HeartMate II Left Ventricular Assist Device Patients With Gastrointestinal Bleeding Niyada Naksuk, Eva Tone, Prangthip Charoenpong, Brian S. Milavitz, Ranjit John, Peter M. Eckman; Cardiology Division, University of Minnesota, Minneapolis, MN Introduction: Gastrointestinal (GI) bleeding is a common complication of continuous-flow left ventricular assist devices (LVADs), but there is little data on the resource needs of its evaluation and management. We examined resource utilization of LVAD patients who were admitted for GI bleeding. Hypothesis: Management of GI bleeding in LVAD patients is resource intensive. Methods: Twenty-four consecutive patients who were admitted for GI bleeding were identified from retrospective chart review of all HeartMate II (HMII) implants at our center. Transfusions, procedures, length of stay (LOS), and hospital cost were evaluated to estimate resource utilization. LOS and cost are represented as median (25th;75th% tile). Results: Mean age was 6469 years, with 42% destination therapy. During their first admission for GI bleeding, 4.364.2 (range 0-18) units of red cells were transfused, 1.861.4 procedures were performed (range 0-6), and LOS was 7 (2;9) days. The estimated direct cost to the hospital for these admissions was $9,765 ($5,563;$16,693). Bleeding etiology was arteriovenous malformation (AVM) in 16 (67%); estimated direct cost in this cohort was $11,101 ($6,671;$17,544), in contrast to $4,919 ($3,601;$7,016) for the 8 who experienced non-AVM bleeding (p50.13). During 2.962.0 years of follow-up, 75% of those with AVM were readmitted, compared to 38% of those with non-AVM bleeding (p50.01). Cost in these readmissions also tended to be higher in patients with AVM bleeding (table). Higher cost in AVM bleeding was driven by higher transfusion and lodging costs, whereas other costs including procedures were comparable.Conclusions: Admission of HMII patients for GI bleeding is resource intensive, particularly in AVM bleeding. This finding highlights the importance of strategies to minimize bleeding in improving the cost effectiveness of this therapy, and reinforces the need for improved understanding of the pathophysiology of AVM bleeding.
Background: Post-operative right ventricular failure leads to considerable morbidity and mortality after left ventricular assist device (LVAD) implantation. The optimal perioperative management strategy for preventing RV failure (RVF) is not well defined. We report the results of a single center experience with a comprehensive management strategy of RV protection aimed at reducing perioperative RVF. Methods: We retrospectively reviewed records from all patients with continuous flow LVADs implanted at our institution from 2007-2011. Preoperative clinical, laboratory and hemodynamic data and postoperative clinical records were evaluated. RVF was adjudicated according to a standard definition of inhaled nitric oxide (NO) useO48 hrs, or inotropic therapyO14 days or need for RVAD post-operatively. The perioperative management strategy of RV protection included delayed sternal closure (up to 72 hours) use of IV milrinone pre-and post op, use of inhaled NO, and individualized use of sildenafil depending on pre-op PVR, PVR/SVR ratio and systemic blood pressure. We compared our rates of RVF to published rates in the Heartmate II destination therapy (DT) trial. We also compared rates of inhaled NO and sildenafil use in the patients who developed RVF vs. those who did not (No RVF). Results: 96 patients (age 59610yrs, 77% male) with continuous flow LVADs (59% BTT, 24% BTD, 15% DT) were implanted during the study period. Of these, 18 patients (19%) developed RVF of whom 3 patients (3%) required RVAD. These ‘real world’ rates of RVF were lower than those seen in the Heartmate II DT trial (24% and 4% respectively) but these differences were not statistically significant (P50.4). Notably mean INTERMACs score was 2.061.1, mean PA pressure was 36610 mmHg and RA pressure was 1367mmHg in our population indicating a similar level of illness to prior studies. Comparing the RVF and no RVF group, use of sildenafil was significantly lower in the RVF vs. no RVF (22% vs. 97%, P!0.001) and there was a trend towards decreased use of inhaled NO in the RVF group (28% vs. 54%, P50.06). Conclusions: Routine perioperative use of sildenafil was associated with lower rates of postoperative RVF. Further, this single center study demonstrates that a comprehensive, targeted perioperative management strategy of RV protection can result in low “real world” rates of RVF, even in those with high INTERMACS scores.
146 Increased Right Ventricle/Left Ventricle Diameter Ratio is Associated With Lack of Right Ventricular Contractile Reserve in Patients With ContinuousFlow Left Ventricular Assist Devices Rey P. Vivo1,2, Andrea M. Cordero-Reyes1, Matthias Loebe1, Brian A. Bruckner1, Guillermo Torre-Amione1, Arvind Bhimaraj1, Jerry D. Estep1; 1Cardiology, Methodist DeBakey Heart & Vascular Center, Houston, TX; 2Cardiology, University of Texas Medical Branch, Galveston, TX Background: Right ventricular (RV) adverse remodeling is common in advanced left-sided heart failure (HF). In patients with baseline RV systolic dysfunction who received a left ventricular assist device (LVAD), we examined pre-implant echocardiographic (TTE) parameters associated with lack of RV contractile reserve (RVCR). Methods: Records and TTE of patients who were implanted with continuous-flow LVAD in our center from 2004-11 were reviewed. Pre-implant RV dysfunction was based on qualitative TTE assessment of at least moderate RV hypokinesis. +RVCR was defined as recovery of RV function to normal or mild hypokinesis post-implant. Patients with no RVCR (-RVCR) included those who showed no improvement in RV function and met the composite outcome of 30-day death or RVF, defined as requirement of an RVAD or $14 consecutive days of inotropes. Student t-test was used to compare continuous variables and P!0.05 was considered significant. Results: 43 patients with significant pre-implant RV systolic dysfunction were included. 25 Table 1. Echo Parameters in LVAD Patients With and Without RV Contractile Reserve (RVCR) +RVCR (n525)
Table 1. Procedures, Red Cell Transfusion, Length of Stay, Direct and Hospital Cost in Study Patients
Procedures Red cell transfusion, units LOS, days Hospital cost (first admission), $ Hospital cost (readmissions), $
All patients n524
Patients with AVM bleeding n516
Patients with non-AVM bleeding n58
P value
1.861.4 4.364.2
2.061.7 5.564.3
1.660.9 1.662.4
0.63 0.03
7.0 (2.0;9.2) 9,765 (5,563; 16,693) 6,070 (5,167; 7,820)
8.0 (4.5;9.3) 11,101 (6,671; 17,544) 6,930 (5,530; 11,453)
3.5 (2.0;9.0) 4,919 (3,601; 7,016) 3,867 (2,694; 6,244)
0.53 0.13 0.34
RV/LV diameter RAVi (mL/m2) PASP/ E/e’ RV S’ RV base diameter (cm) RAP (mmHg) RV fractional area change (%) LAVi (mL/m2) PVR (Wood u)
0.76 47.5 2.9 7.7 5.2 14.2 19.2 53.9 5.4
6 6 6 6 6 6 6 6 6
0.1 17.6 1.8 2.2 0.6 5.3 6.5 18.4 4.5
RVCR (n55) 0.9 63.5 4.5 5.5 5.5 16.8 17.3 47.9 5.1
6 6 6 6 6 6 6 6 6
0.1 17.9 0.3 1.5 0.5 7.8 4.1 21.0 1.0
P value 0.02 0.07 0.09 0.1 0.3 0.4 0.5 0.5 0.8
RAVi 5 Right atrial volume index; Pulmonary artery systolic pressure; E/e’ 5 Mitral inflow early filling peak velocity/early diastolic mitral annular velocity; RV S’ 5 systolic excursion velocity; RAP 5 right atrial pressure; LAVi 5 Left atrial volume index; PVR 5 Pulmonary vascular resistance (Abbas formula)
HFSA
S45
145 An Aggressive, Targeted Perioperative Management Strategy Results in Low Rates of Postoperative Right Ventricular Failure After Left Ventricular Assist Device Implantation Amresh Raina, Manreet Kanwar, George Sokos, Robert Moraca, Stephen Bailey, Raymond L. Benza, Srinivas Murali; Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA
mean BP at presentation, require more red cell transfusions and have a higher rate or recurrent bleeding compared to those with non-AVM bleeding. However, mortality at 3 year follow-up is comparable in both groups.
144 Resource Utilization in HeartMate II Left Ventricular Assist Device Patients With Gastrointestinal Bleeding Niyada Naksuk, Eva Tone, Prangthip Charoenpong, Brian S. Milavitz, Ranjit John, Peter M. Eckman; Cardiology Division, University of Minnesota, Minneapolis, MN Introduction: Gastrointestinal (GI) bleeding is a common complication of continuous-flow left ventricular assist devices (LVADs), but there is little data on the resource needs of its evaluation and management. We examined resource utilization of LVAD patients who were admitted for GI bleeding. Hypothesis: Management of GI bleeding in LVAD patients is resource intensive. Methods: Twenty-four consecutive patients who were admitted for GI bleeding were identified from retrospective chart review of all HeartMate II (HMII) implants at our center. Transfusions, procedures, length of stay (LOS), and hospital cost were evaluated to estimate resource utilization. LOS and cost are represented as median (25th;75th% tile). Results: Mean age was 6469 years, with 42% destination therapy. During their first admission for GI bleeding, 4.364.2 (range 0-18) units of red cells were transfused, 1.861.4 procedures were performed (range 0-6), and LOS was 7 (2;9) days. The estimated direct cost to the hospital for these admissions was $9,765 ($5,563;$16,693). Bleeding etiology was arteriovenous malformation (AVM) in 16 (67%); estimated direct cost in this cohort was $11,101 ($6,671;$17,544), in contrast to $4,919 ($3,601;$7,016) for the 8 who experienced non-AVM bleeding (p50.13). During 2.962.0 years of follow-up, 75% of those with AVM were readmitted, compared to 38% of those with non-AVM bleeding (p50.01). Cost in these readmissions also tended to be higher in patients with AVM bleeding (table). Higher cost in AVM bleeding was driven by higher transfusion and lodging costs, whereas other costs including procedures were comparable.Conclusions: Admission of HMII patients for GI bleeding is resource intensive, particularly in AVM bleeding. This finding highlights the importance of strategies to minimize bleeding in improving the cost effectiveness of this therapy, and reinforces the need for improved understanding of the pathophysiology of AVM bleeding.
Background: Post-operative right ventricular failure leads to considerable morbidity and mortality after left ventricular assist device (LVAD) implantation. The optimal perioperative management strategy for preventing RV failure (RVF) is not well defined. We report the results of a single center experience with a comprehensive management strategy of RV protection aimed at reducing perioperative RVF. Methods: We retrospectively reviewed records from all patients with continuous flow LVADs implanted at our institution from 2007-2011. Preoperative clinical, laboratory and hemodynamic data and postoperative clinical records were evaluated. RVF was adjudicated according to a standard definition of inhaled nitric oxide (NO) useO48 hrs, or inotropic therapyO14 days or need for RVAD post-operatively. The perioperative management strategy of RV protection included delayed sternal closure (up to 72 hours) use of IV milrinone pre-and post op, use of inhaled NO, and individualized use of sildenafil depending on pre-op PVR, PVR/SVR ratio and systemic blood pressure. We compared our rates of RVF to published rates in the Heartmate II destination therapy (DT) trial. We also compared rates of inhaled NO and sildenafil use in the patients who developed RVF vs. those who did not (No RVF). Results: 96 patients (age 59610yrs, 77% male) with continuous flow LVADs (59% BTT, 24% BTD, 15% DT) were implanted during the study period. Of these, 18 patients (19%) developed RVF of whom 3 patients (3%) required RVAD. These ‘real world’ rates of RVF were lower than those seen in the Heartmate II DT trial (24% and 4% respectively) but these differences were not statistically significant (P50.4). Notably mean INTERMACs score was 2.061.1, mean PA pressure was 36610 mmHg and RA pressure was 1367mmHg in our population indicating a similar level of illness to prior studies. Comparing the RVF and no RVF group, use of sildenafil was significantly lower in the RVF vs. no RVF (22% vs. 97%, P!0.001) and there was a trend towards decreased use of inhaled NO in the RVF group (28% vs. 54%, P50.06). Conclusions: Routine perioperative use of sildenafil was associated with lower rates of postoperative RVF. Further, this single center study demonstrates that a comprehensive, targeted perioperative management strategy of RV protection can result in low “real world” rates of RVF, even in those with high INTERMACS scores.
146 Increased Right Ventricle/Left Ventricle Diameter Ratio is Associated With Lack of Right Ventricular Contractile Reserve in Patients With ContinuousFlow Left Ventricular Assist Devices Rey P. Vivo1,2, Andrea M. Cordero-Reyes1, Matthias Loebe1, Brian A. Bruckner1, Guillermo Torre-Amione1, Arvind Bhimaraj1, Jerry D. Estep1; 1Cardiology, Methodist DeBakey Heart & Vascular Center, Houston, TX; 2Cardiology, University of Texas Medical Branch, Galveston, TX Background: Right ventricular (RV) adverse remodeling is common in advanced left-sided heart failure (HF). In patients with baseline RV systolic dysfunction who received a left ventricular assist device (LVAD), we examined pre-implant echocardiographic (TTE) parameters associated with lack of RV contractile reserve (RVCR). Methods: Records and TTE of patients who were implanted with continuous-flow LVAD in our center from 2004-11 were reviewed. Pre-implant RV dysfunction was based on qualitative TTE assessment of at least moderate RV hypokinesis. +RVCR was defined as recovery of RV function to normal or mild hypokinesis post-implant. Patients with no RVCR (-RVCR) included those who showed no improvement in RV function and met the composite outcome of 30-day death or RVF, defined as requirement of an RVAD or $14 consecutive days of inotropes. Student t-test was used to compare continuous variables and P!0.05 was considered significant. Results: 43 patients with significant pre-implant RV systolic dysfunction were included. 25 Table 1. Echo Parameters in LVAD Patients With and Without RV Contractile Reserve (RVCR) +RVCR (n525)
Table 1. Procedures, Red Cell Transfusion, Length of Stay, Direct and Hospital Cost in Study Patients
Procedures Red cell transfusion, units LOS, days Hospital cost (first admission), $ Hospital cost (readmissions), $
All patients n524
Patients with AVM bleeding n516
Patients with non-AVM bleeding n58
P value
1.861.4 4.364.2
2.061.7 5.564.3
1.660.9 1.662.4
0.63 0.03
7.0 (2.0;9.2) 9,765 (5,563; 16,693) 6,070 (5,167; 7,820)
8.0 (4.5;9.3) 11,101 (6,671; 17,544) 6,930 (5,530; 11,453)
3.5 (2.0;9.0) 4,919 (3,601; 7,016) 3,867 (2,694; 6,244)
0.53 0.13 0.34
RV/LV diameter RAVi (mL/m2) PASP/ E/e’ RV S’ RV base diameter (cm) RAP (mmHg) RV fractional area change (%) LAVi (mL/m2) PVR (Wood u)
0.76 47.5 2.9 7.7 5.2 14.2 19.2 53.9 5.4
6 6 6 6 6 6 6 6 6
0.1 17.6 1.8 2.2 0.6 5.3 6.5 18.4 4.5
RVCR (n55) 0.9 63.5 4.5 5.5 5.5 16.8 17.3 47.9 5.1
6 6 6 6 6 6 6 6 6
0.1 17.9 0.3 1.5 0.5 7.8 4.1 21.0 1.0
P value 0.02 0.07 0.09 0.1 0.3 0.4 0.5 0.5 0.8
RAVi 5 Right atrial volume index; Pulmonary artery systolic pressure; E/e’ 5 Mitral inflow early filling peak velocity/early diastolic mitral annular velocity; RV S’ 5 systolic excursion velocity; RAP 5 right atrial pressure; LAVi 5 Left atrial volume index; PVR 5 Pulmonary vascular resistance (Abbas formula)