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Right Ventricular Spherical Dilatation Combined with Pulmonary Artery Compliance Predicts Severe-Acute Right Heart Failure after LVAD Implantation
The 23rd Annual Scientific Meeting HFSA
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463 Right Ventricular Spherical Dilatation Combined with Pulmonary Artery Compliance Predicts Severe-Acute Right Heart Failure after LVAD Implantation Arune A. Gulati1, Kristin A. Freed1, Roberta Florido1, Nisha A. Gilotra1, Kavita Sharma1, Ryan J. Tedford2, Chun W. Choi1, Ahmet Kilic1, Steven Hsu1; 1Johns Hopkins Hospital, Baltimore, MD; 2Medical University of South Carolina, Charleston, SC
Figure 1. Exchange-free survival in LVAD patients.
462 LVAD as Bridge to Transplant Leads to Better Outcomes When Compared to Transplant-Only Strategy Baldeep Dhaliwal, Miriam Becnel, Francisco Merced-Ortiz, Stacy Mandras, Sapna Desai, Hamang Patel, Clement Eiswirth, Hector Ventura, Selim Krim; Ochsner Medical Center, New Orleans, LA Background: Patient who are bridged to transplantation with a left ventricular assist device (LVAD) when compared to primary heart transplantation have had mixed outcomes. Methods: Single-center study of patients who underwent cardiac transplantation or LVAD implantation. Baseline demographics and outcomes were compared between 3 groups: patients bridged with a LVAD (BTT-LVAD group), patients who underwent primary cardiac transplantation (TXP group), and patients who underwent LVAD as destination therapy (DT-LVAD group). For the TXP group, survival was defined as days alive since cardiac transplantation. For the BTT-LVAD group, survival was defined from time of LVAD implantation and included days alive after cardiac transplantation. In the DT-LVAD group, survival was defined as days alive since LVAD implantation. Kaplan-Meier curves were used to analyze survival between the groups. Results: A total of 380 patients were included (BTT-LVAD group: 36.3.%; TXP group: 26%; DTLVAD group: 37.6%). At baseline, no significant differences with regards to age and BMI were noted. Male gender and blood type O were more common in the BTT-LVAD group. The DT-LVAD group had a higher proportion of black patients. During the study period, 76% of LVAD-BTT group underwent cardiac transplantation. A high survival rate was observed is the study population at 1-year (92.1%). Non-statistically significant differences in 1-year survival were noted between groups with higher trends of survival observed in the BTT-LVAD group (BTT-LVAD group: 95.7%; TXP group: 90.9%; DT-LVAD group: 89.5%, p=0.14). By 2 years, survival rates remained high in all groups with statistically significant differences noted among the groups (BTT-LVAD group: 94.6%; TXP group: 85.9%; DT-LVAD group: 81.4%, p=0.01). 3-year survival remained high for both the BTT-LVAD and TXP groups however, a decline in survival was noted in the DT-LVAD group (BTT-LVAD group: 93.5%; TXP group: 81.6%; DT-LVAD group: 60.8%, p=0.00). While 5-year survival remained high for the LVAD-BTT group (figure), a further survival decrease was observed in both the TXP and DT-LVAD groups (BTT-LVAD group:8 4.2%; TXP group: 63%; DT-LVAD group: 29.8%, p=0.00). Conclusions: Our study showed an exceptionally high survival rate in patients bridged to cardiac transplantation with LVAD implantation. These findings also suggest that the use of a LVAD as a BTT may be a better strategy than primary cardiac transplantation as it may add an additional survival benefit (total support time).
Background: Right heart failure (RHF) remains a major contributor to morbidity and mortality after left ventricular assist device (LVAD) implantation. Our ability to predict which patients are at highest risk for RHF remains limited. Pulmonary artery compliance (PAC), as a measure of right ventricular (RV) pulsatile load, is associated with RHF after LVAD. We hypothesized that the addition of RV spherical dilatation, which indexes the RV response to load, could further characterize the risk of post LVAD RHF. Methods: We retrospectively studied 144 patients who underwent durable LVAD between 2009 and 2018 at our center and had both preoperative echocardiographic and hemodynamic data. RV spherical dilatation (RVs) was indexed by the RV basal short axis length in the apical 4-chamber view. PAC was calculated as SV/(PASP-PADP) and was indexed to body surface area to generate PACi. We generated a new composite variable, the Sphericity Index (SpI), where SpI = RVs/PACi; higher SpI values indicate more composite RV dilatation and pulsatile load. RHF was defined per INTERMACS classifications, with Severe RHF being 14d postoperative inotrope dependence and Severe-Acute RHF being need for RVAD or death from RHF. Multivariate logistic regression modeling was used to assess the relationship between SpI and PACi to both Severe and Severe-Acute RHF. Results: Forty patients (27.8%) developed Severe RHF and 14 patients (9.7%) developed SevereAcute RHF. Median PACi and SpI were 0.72 ml/mmHg/m2 (IQR 0.44 ml/mmHg/m2) and 1.62 cm*mmHg/ml/m2 (IQR 1.04 cm*mmHg/ml/m2), respectively. Lower PACi (OR 0.16 [0.04-0.64], p = 0.01) and higher SpI (OR 1.79 [1.12-2.83], p = 0.01) were associated with Severe RHF, adjusted for INTERMACS profile and heart rate. However, only SpI was associated with Severe-Acute RHF (OR 2.69 [1.44-5.00], p = 0.002), whereas PACi did not reach significance (p = 0.06). Conclusion: SpI, a composite index combining RV spherical dilatation and PACi, characterizes both RV load and response to load and may predict Severe-Acute RHF after LVAD better than PACi alone.
464 Left Ventricular Assist Devices vs. Cardiac Transplantation: The Age Factor Baldeep Dhaliwal, Miriam Becnel, Francisco Merced-Ortiz, Sapna Desai, Stacy Mandras, Hamang Patel, Clement Eiswirth, Hector Ventura, Selim Krim; Ochsner Medical Center, New Orleans, LA Background: Outcomes of patients bridged with a left ventricular assist device (LVAD) when compared to primary cardiac transplantation may vary by age group. Methods: Single-center study of patients who underwent cardiac transplantation or LVAD implantation. The study population was categorized by age groups. Group 1 included patients under 50 years of age, while Group 2 included patients over 50 years of age. For each age group, separate analyses of baseline demographics and outcomes were compared between 3 subgroups: patients bridged with an LVAD (BTT-LVAD group), primary cardiac transplantation patients (TXP group), and destination therapy (DT-LVAD group). For the BTT-LVAD group, survival was assessed from time of LVAD implantation and included days alive after cardiac transplantation. For the TXP group, survival was defined as days alive since transplantation. Kaplan-Meier curves were used to analyze survival between groups. Results: A total of 380 patients were analyzed in the study. 136 patients were included in Group 1 (35.8%). At baseline, no significant differences with regards to age, gender, ethnicity and BMI were noted among subgroups. During the study period, 76% of Group 1 BTT-LVAD patients underwent transplantation. A high survival rate was observed with no significant differences in 1-year survival noted between subgroups (Group 1 BTT-LVAD: 96%; Group 1 TXP: 97.3%; Group 1 DT-LVAD:91.8%, p=0.472). 3-year survival remained high in Group 1 BTT-LVAD patients, but a significant decrease in survival of both Group 1 TXP and DT-LVAD was noted (Fig. A). Group 2 patients comprised 244 patients (64.2% of total population; Group 2 BTT-LVAD: 36.1.%; Group 2 TXP: 25.4%; Group 2 DT-LVAD: 38.5%). At baseline, no significant differences with regards to age, gender, BMI were noted among subgroups. Group 2 DT-LVAD had a higher proportion of black patients. During the study period, 76% of Group 2 BTT-LVAD patients underwent transplantation. A high survival rate was observed in Group 2 with no significant differences in 1-year survival noted between subgroups (Group 2 BTT-LVAD: 95.5%; Group 2 TXP: 87.1%; Group 2 DT-LVAD: 88.3%, p=0.14). 3-year survival remained high in Group 2 BTT-LVAD and TXP, but a significant decrease in survival of Group 2 DT-LVAD was noted (Fig. B). Conclusions: Our study showed exceptionally high mid- and long-term survival rates in patients bridged with a LVAD in both age groups. While a TXP strategy may be reasonable in older patients, younger patients who underwent TXP had a significant decline in survival at 3 and 5 years. Conversely, outcomes of DT-LVAD therapy in younger patients continues to improve.
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463 Right Ventricular Spherical Dilatation Combined with Pulmonary Artery Compliance Predicts Severe-Acute Right Heart Failure after LVAD Implantation Arune A. Gulati1, Kristin A. Freed1, Roberta Florido1, Nisha A. Gilotra1, Kavita Sharma1, Ryan J. Tedford2, Chun W. Choi1, Ahmet Kilic1, Steven Hsu1; 1Johns Hopkins Hospital, Baltimore, MD; 2Medical University of South Carolina, Charleston, SC
Figure 1. Exchange-free survival in LVAD patients.
462 LVAD as Bridge to Transplant Leads to Better Outcomes When Compared to Transplant-Only Strategy Baldeep Dhaliwal, Miriam Becnel, Francisco Merced-Ortiz, Stacy Mandras, Sapna Desai, Hamang Patel, Clement Eiswirth, Hector Ventura, Selim Krim; Ochsner Medical Center, New Orleans, LA Background: Patient who are bridged to transplantation with a left ventricular assist device (LVAD) when compared to primary heart transplantation have had mixed outcomes. Methods: Single-center study of patients who underwent cardiac transplantation or LVAD implantation. Baseline demographics and outcomes were compared between 3 groups: patients bridged with a LVAD (BTT-LVAD group), patients who underwent primary cardiac transplantation (TXP group), and patients who underwent LVAD as destination therapy (DT-LVAD group). For the TXP group, survival was defined as days alive since cardiac transplantation. For the BTT-LVAD group, survival was defined from time of LVAD implantation and included days alive after cardiac transplantation. In the DT-LVAD group, survival was defined as days alive since LVAD implantation. Kaplan-Meier curves were used to analyze survival between the groups. Results: A total of 380 patients were included (BTT-LVAD group: 36.3.%; TXP group: 26%; DTLVAD group: 37.6%). At baseline, no significant differences with regards to age and BMI were noted. Male gender and blood type O were more common in the BTT-LVAD group. The DT-LVAD group had a higher proportion of black patients. During the study period, 76% of LVAD-BTT group underwent cardiac transplantation. A high survival rate was observed is the study population at 1-year (92.1%). Non-statistically significant differences in 1-year survival were noted between groups with higher trends of survival observed in the BTT-LVAD group (BTT-LVAD group: 95.7%; TXP group: 90.9%; DT-LVAD group: 89.5%, p=0.14). By 2 years, survival rates remained high in all groups with statistically significant differences noted among the groups (BTT-LVAD group: 94.6%; TXP group: 85.9%; DT-LVAD group: 81.4%, p=0.01). 3-year survival remained high for both the BTT-LVAD and TXP groups however, a decline in survival was noted in the DT-LVAD group (BTT-LVAD group: 93.5%; TXP group: 81.6%; DT-LVAD group: 60.8%, p=0.00). While 5-year survival remained high for the LVAD-BTT group (figure), a further survival decrease was observed in both the TXP and DT-LVAD groups (BTT-LVAD group:8 4.2%; TXP group: 63%; DT-LVAD group: 29.8%, p=0.00). Conclusions: Our study showed an exceptionally high survival rate in patients bridged to cardiac transplantation with LVAD implantation. These findings also suggest that the use of a LVAD as a BTT may be a better strategy than primary cardiac transplantation as it may add an additional survival benefit (total support time).
Background: Right heart failure (RHF) remains a major contributor to morbidity and mortality after left ventricular assist device (LVAD) implantation. Our ability to predict which patients are at highest risk for RHF remains limited. Pulmonary artery compliance (PAC), as a measure of right ventricular (RV) pulsatile load, is associated with RHF after LVAD. We hypothesized that the addition of RV spherical dilatation, which indexes the RV response to load, could further characterize the risk of post LVAD RHF. Methods: We retrospectively studied 144 patients who underwent durable LVAD between 2009 and 2018 at our center and had both preoperative echocardiographic and hemodynamic data. RV spherical dilatation (RVs) was indexed by the RV basal short axis length in the apical 4-chamber view. PAC was calculated as SV/(PASP-PADP) and was indexed to body surface area to generate PACi. We generated a new composite variable, the Sphericity Index (SpI), where SpI = RVs/PACi; higher SpI values indicate more composite RV dilatation and pulsatile load. RHF was defined per INTERMACS classifications, with Severe RHF being 14d postoperative inotrope dependence and Severe-Acute RHF being need for RVAD or death from RHF. Multivariate logistic regression modeling was used to assess the relationship between SpI and PACi to both Severe and Severe-Acute RHF. Results: Forty patients (27.8%) developed Severe RHF and 14 patients (9.7%) developed SevereAcute RHF. Median PACi and SpI were 0.72 ml/mmHg/m2 (IQR 0.44 ml/mmHg/m2) and 1.62 cm*mmHg/ml/m2 (IQR 1.04 cm*mmHg/ml/m2), respectively. Lower PACi (OR 0.16 [0.04-0.64], p = 0.01) and higher SpI (OR 1.79 [1.12-2.83], p = 0.01) were associated with Severe RHF, adjusted for INTERMACS profile and heart rate. However, only SpI was associated with Severe-Acute RHF (OR 2.69 [1.44-5.00], p = 0.002), whereas PACi did not reach significance (p = 0.06). Conclusion: SpI, a composite index combining RV spherical dilatation and PACi, characterizes both RV load and response to load and may predict Severe-Acute RHF after LVAD better than PACi alone.
464 Left Ventricular Assist Devices vs. Cardiac Transplantation: The Age Factor Baldeep Dhaliwal, Miriam Becnel, Francisco Merced-Ortiz, Sapna Desai, Stacy Mandras, Hamang Patel, Clement Eiswirth, Hector Ventura, Selim Krim; Ochsner Medical Center, New Orleans, LA Background: Outcomes of patients bridged with a left ventricular assist device (LVAD) when compared to primary cardiac transplantation may vary by age group. Methods: Single-center study of patients who underwent cardiac transplantation or LVAD implantation. The study population was categorized by age groups. Group 1 included patients under 50 years of age, while Group 2 included patients over 50 years of age. For each age group, separate analyses of baseline demographics and outcomes were compared between 3 subgroups: patients bridged with an LVAD (BTT-LVAD group), primary cardiac transplantation patients (TXP group), and destination therapy (DT-LVAD group). For the BTT-LVAD group, survival was assessed from time of LVAD implantation and included days alive after cardiac transplantation. For the TXP group, survival was defined as days alive since transplantation. Kaplan-Meier curves were used to analyze survival between groups. Results: A total of 380 patients were analyzed in the study. 136 patients were included in Group 1 (35.8%). At baseline, no significant differences with regards to age, gender, ethnicity and BMI were noted among subgroups. During the study period, 76% of Group 1 BTT-LVAD patients underwent transplantation. A high survival rate was observed with no significant differences in 1-year survival noted between subgroups (Group 1 BTT-LVAD: 96%; Group 1 TXP: 97.3%; Group 1 DT-LVAD:91.8%, p=0.472). 3-year survival remained high in Group 1 BTT-LVAD patients, but a significant decrease in survival of both Group 1 TXP and DT-LVAD was noted (Fig. A). Group 2 patients comprised 244 patients (64.2% of total population; Group 2 BTT-LVAD: 36.1.%; Group 2 TXP: 25.4%; Group 2 DT-LVAD: 38.5%). At baseline, no significant differences with regards to age, gender, BMI were noted among subgroups. Group 2 DT-LVAD had a higher proportion of black patients. During the study period, 76% of Group 2 BTT-LVAD patients underwent transplantation. A high survival rate was observed in Group 2 with no significant differences in 1-year survival noted between subgroups (Group 2 BTT-LVAD: 95.5%; Group 2 TXP: 87.1%; Group 2 DT-LVAD: 88.3%, p=0.14). 3-year survival remained high in Group 2 BTT-LVAD and TXP, but a significant decrease in survival of Group 2 DT-LVAD was noted (Fig. B). Conclusions: Our study showed exceptionally high mid- and long-term survival rates in patients bridged with a LVAD in both age groups. While a TXP strategy may be reasonable in older patients, younger patients who underwent TXP had a significant decline in survival at 3 and 5 years. Conversely, outcomes of DT-LVAD therapy in younger patients continues to improve.