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The Nutritional Risk Index as a Marker for Outcomes Following Left Ventricular Assist Device Implantation
S340
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
9( 39) Measuring Blood Pressure in Patients with Continuous-Flow Left Ventricular Assist Devices K.L. Kerk ,1 T.H. Truong,2 C.H. Lim,1 T.E. Tan,1 D. Sim,3 C.P. Lim,3 C. Sivathasan.1 1Cardiothoracic Surgery, National Heart Centre Singapore, Singapore, Singapore; 2SingHealth Transplant, Singapore Health Services, Singapore, Singapore; 3Cardiology, National Heart Centre Singapore, Singapore, Singapore. Purpose: Management of blood pressure (Bp) in patients with continuous flow LVADs is practised in optimising cardiac output. It may also reduce the incidence of stroke and progression of aortic regurgitation. The intra-arterial (IA) pressure, although the gold standard, is an invasive procedure and is not practical for routine outpatient monitoring. Hence Doppler is widely used to measure BP in this group of patients. We report our experience measuring non-invasive Bp (NIBP) by an automated oscillometric (automatic) devices, Doppler and Pulse oximetry waveform recordings with sphygmomanometry. Methods: A prospective review of blood pressure measurement was performed during outpatient visits from March to October 2015 on 40 patients who underwent HeartMate II (HMII) and HeartWare (HVAD) LVAD implantation between May 2009 to August 2015 as bridge to transplant and destination therapy in our centre. A total of 87 readings were recorded by NIBP, Doppler and Pulse oximetry. Descriptive and mean comparison analysis was done. Wilcoxon Signed Rank test and Mann-Whitney U test were used to compare median BP measured by the 3 methods. Any p value ≤ 0.05 was deemed statistically significant. Results: BPs measured by Doppler and Pulse oximetry methods was not statistically different. The mean Bp measured using Doppler was 83.24mmHg as compared to 82.15 mmHg by Pulse oximetry. This was applicable to all Bp readings (p= 0.561), regardless whether aortic valve opens during systole (p= 0.562) or remains closed (p= 0.693). However, the mean Bp measured by NIBP was significantly (p< 0.001) lower than by Pulse oximetry. The mean BP measured by Pulse oximetry did not tally with the systolic BP measured by NIBP in patients where the aortic valve opens with every beat. Conclusion: Bp measured by Doppler and Pulse oximetry was comparable, regardless aortic valve opens or remains closed. With the widely available Pulse oximetry, we can measure Bp for LVAD patients more readily even in the setting of emergency department or outpatient clinics where the Doppler may not be available. 9( 40) The Nutritional Risk Index as a Marker for Outcomes Following Left Ventricular Assist Device Implantation G. Yost ,1 G. Bhat.2 1Heart Transplant, Advocate Christ Medical Center, Oak Lawn, IL; 2Heart Institute, Advocate Christ Medical Center, Oak Lawn, IL. Purpose: Malnutrition is common in patients with advanced heart failure (AHF) and is known to negatively impact survival after left ventricular assist device (LVAD) implantation. Though many patients who are evaluated for LVAD present with clinical indicators of advanced malnutrition and/or cardiac cachexia, the paucity of tools for comprehensive evaluation of nutritional status makes patient selection challenging. We evaluated the use of the nutritional risk index (NRI) as a predictor of post-LVAD outcomes. Methods: This study included 283 patients who underwent LVAD implantation between 2006 and 2014. NRI was calculated for all patients as (1.519 x serum albumin, g/dL) + (41.7 × {present weight, kg/ideal body weight, kg}). The group was divided into tertiles, with tertile 1 representing the highest risk patients and tertile 3 the lowest risk. Outcomes were compared between tertiles. Results: The mean NRI score was 57.2 ± 12.1 with max 106.2, min 33.9 and skewness 0.89. When divided into 3 groups, mean NRI was significantly different between tertiles. Patients with low NRI (high-risk) had significantly lower body mass index, and pre-albumin as well as increased b-type natriuretic peptide (BNP) and age. Outcomes, including 1-year survival, readmission within 1 year, and post-operative length of stay were not significantly different between tertiles. Conclusion: Nutritional status, per the NRI, was not an indicator of postoperative outcomes following LVAD implantation. Major nutrition-related risk in the hospitalized patient is defined by an NRI score less than 83.5. We found that 96.9% of our AHF population was, by this definition, at major risk, while only 1 patient (0.4%) was classified as mild or no risk. This
appears to be primarily a result of reduced serum albumin in this population (mean albumin 3.0 ± 0.47 g/dL). It appears that low albumin levels and labile fluid status may render the NRI an ineffective means of assessing post-operative outcomes in AHF patients undergoing LVAD. Table 1
Parameter NRI Age (years) BMI (kg/m2) Gender (#male) MAP (mmHg) LVEDD (mm) LVEF (%) Creatinine (mg/dL) BNP (pg/dL 365 day readmission 365 day survival Post operative length of stay (days)
NRI Tertile 1 (n= 94)
NRI Tertile 2 (n= 94)
NRI Tertile 3 (n= 95)
P-Value
45.4 ± 3.8 62.2 ± 12.5 21.4 ± 2.1
55.1 ± 2.9 62.84 ± 10.8 26.9 ± 1.8
71.1 ± 8.8 53.1 ± 13.1 34.2 ± 4.0
> 0.001 > 0.001 > 0.001
72 (82.8%) 76.5 ± 11.3 67.2 ± 8.8 18.3 ± 6.7 1.3 ± 0.5 762.0 (676) 48 (55.2%) 47 (71.2%) 25.0 ± 18.7
76 (86.4%) 80.8 ± 14.3 67.2 ± 10.4 18.3 ± 6.7 1.4 ± 0.5 629.0 (678) 39 (44.3%) 49 (86.0%) 24.2 ± 15.6
61 (69.3%) 82.8 ± 11.5 67.6 ± 13.3 20.6 ± 9.0 1.5 ± 0.5 287.0 (595) 56 (63.6%) 50 (80.6%) 24.4 ± 19.1
0.013 0.040 0.976 0.286 0.051 > 0.001 0.700 0.124 0.960
9( 41) Integration of Palliative Care in End of Life Care for Patients on Durable Mechanical Circulatory Support H.J. Halazun ,1 S. Pinney,1 N. Goldstein,2 L. Gelfman,2 K. Ashley,1 A. Anyanwu,1 A. Lala.1 1Cardiology, Mount Sinai Heart, New York, NY; 2Palliative Care, Mount Sinai, New York, NY. Purpose: Although outcomes for patients on durable ventricular assist device therapy (VAD) continue to improve, patients are still plagued with frequent hospitalizations and limited long-term survival. Little data exists on the optimal timing of and setting for palliative care involvement for these patients. We conducted a retrospective chart review of our single center’s experience to understand how and where VAD patients die. Methods: Charts for all patients who died after receiving a durable VAD between August 2008 and January 2015 were reviewed. Only patients who survived index hospitalization and subsequently died on VAD support were included for analysis. Data on demographic, VAD implant data, medical complications, and palliative care utilization were abstracted retrospectively. Results: A total of 62 patients died following VAD implant for either bridge to transplantation (BTT) (49 (79%)) or destination therapy (DT) (13(21%)). Of those, 37 (60%) patients died during the index hospitalization and 25 (40%) patients survived the index hospitalization but ultimately died on VAD support (BTT 66%, DT 34%). Their mean age at time of implant was 59.0 (SD 11.6) years and 84% were male. These patients lived an average of 15.6 (SD 12.4) months on VAD support. Inpatient palliative care team consultation occurred for 12 (48%) of patients at an average of 23.6 (SD 65.3) days prior to death. Causes of death were identified as intracranial bleeding (8 (32%)); pump complications (5 (20%)); sepsis (4 (16%)); multi-organ system failure (3 (12%)), respiratory failure (2 (8%)) and unknown (3 (12%)). Deaths were thought to be sudden, or unexpected, in 14 (56%) patients. Sixteen (64%) patients died in the hospital, 5 (20%) died at home and 4 (16%) died in inpatient hospice. Conclusion: The majority of VAD patients die in hospital settings, but many die at home, and die suddenly. Although palliative care consultation occurred in nearly half of these patients with durable VAD, palliative care was consulted months after VAD implant and near the end of life. There is ongoing need for earlier involvement of palliative care for this population, particularly in the outpatient setting, as a way to improve advanced care planning, symptom management, alignment of treatment preferences with treatments received, as well as caregiver bereavement. 9( 42) Hospital Readmissions After Left Ventricular Assist Device Implantation C. Heim , N. Mekkhala, M. Kondruweit, M. Weyand, R. Tandler. Department of Cardiac Surgery, University of Erlangen, Erlangen, Germany.
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
9( 39) Measuring Blood Pressure in Patients with Continuous-Flow Left Ventricular Assist Devices K.L. Kerk ,1 T.H. Truong,2 C.H. Lim,1 T.E. Tan,1 D. Sim,3 C.P. Lim,3 C. Sivathasan.1 1Cardiothoracic Surgery, National Heart Centre Singapore, Singapore, Singapore; 2SingHealth Transplant, Singapore Health Services, Singapore, Singapore; 3Cardiology, National Heart Centre Singapore, Singapore, Singapore. Purpose: Management of blood pressure (Bp) in patients with continuous flow LVADs is practised in optimising cardiac output. It may also reduce the incidence of stroke and progression of aortic regurgitation. The intra-arterial (IA) pressure, although the gold standard, is an invasive procedure and is not practical for routine outpatient monitoring. Hence Doppler is widely used to measure BP in this group of patients. We report our experience measuring non-invasive Bp (NIBP) by an automated oscillometric (automatic) devices, Doppler and Pulse oximetry waveform recordings with sphygmomanometry. Methods: A prospective review of blood pressure measurement was performed during outpatient visits from March to October 2015 on 40 patients who underwent HeartMate II (HMII) and HeartWare (HVAD) LVAD implantation between May 2009 to August 2015 as bridge to transplant and destination therapy in our centre. A total of 87 readings were recorded by NIBP, Doppler and Pulse oximetry. Descriptive and mean comparison analysis was done. Wilcoxon Signed Rank test and Mann-Whitney U test were used to compare median BP measured by the 3 methods. Any p value ≤ 0.05 was deemed statistically significant. Results: BPs measured by Doppler and Pulse oximetry methods was not statistically different. The mean Bp measured using Doppler was 83.24mmHg as compared to 82.15 mmHg by Pulse oximetry. This was applicable to all Bp readings (p= 0.561), regardless whether aortic valve opens during systole (p= 0.562) or remains closed (p= 0.693). However, the mean Bp measured by NIBP was significantly (p< 0.001) lower than by Pulse oximetry. The mean BP measured by Pulse oximetry did not tally with the systolic BP measured by NIBP in patients where the aortic valve opens with every beat. Conclusion: Bp measured by Doppler and Pulse oximetry was comparable, regardless aortic valve opens or remains closed. With the widely available Pulse oximetry, we can measure Bp for LVAD patients more readily even in the setting of emergency department or outpatient clinics where the Doppler may not be available. 9( 40) The Nutritional Risk Index as a Marker for Outcomes Following Left Ventricular Assist Device Implantation G. Yost ,1 G. Bhat.2 1Heart Transplant, Advocate Christ Medical Center, Oak Lawn, IL; 2Heart Institute, Advocate Christ Medical Center, Oak Lawn, IL. Purpose: Malnutrition is common in patients with advanced heart failure (AHF) and is known to negatively impact survival after left ventricular assist device (LVAD) implantation. Though many patients who are evaluated for LVAD present with clinical indicators of advanced malnutrition and/or cardiac cachexia, the paucity of tools for comprehensive evaluation of nutritional status makes patient selection challenging. We evaluated the use of the nutritional risk index (NRI) as a predictor of post-LVAD outcomes. Methods: This study included 283 patients who underwent LVAD implantation between 2006 and 2014. NRI was calculated for all patients as (1.519 x serum albumin, g/dL) + (41.7 × {present weight, kg/ideal body weight, kg}). The group was divided into tertiles, with tertile 1 representing the highest risk patients and tertile 3 the lowest risk. Outcomes were compared between tertiles. Results: The mean NRI score was 57.2 ± 12.1 with max 106.2, min 33.9 and skewness 0.89. When divided into 3 groups, mean NRI was significantly different between tertiles. Patients with low NRI (high-risk) had significantly lower body mass index, and pre-albumin as well as increased b-type natriuretic peptide (BNP) and age. Outcomes, including 1-year survival, readmission within 1 year, and post-operative length of stay were not significantly different between tertiles. Conclusion: Nutritional status, per the NRI, was not an indicator of postoperative outcomes following LVAD implantation. Major nutrition-related risk in the hospitalized patient is defined by an NRI score less than 83.5. We found that 96.9% of our AHF population was, by this definition, at major risk, while only 1 patient (0.4%) was classified as mild or no risk. This
appears to be primarily a result of reduced serum albumin in this population (mean albumin 3.0 ± 0.47 g/dL). It appears that low albumin levels and labile fluid status may render the NRI an ineffective means of assessing post-operative outcomes in AHF patients undergoing LVAD. Table 1
Parameter NRI Age (years) BMI (kg/m2) Gender (#male) MAP (mmHg) LVEDD (mm) LVEF (%) Creatinine (mg/dL) BNP (pg/dL 365 day readmission 365 day survival Post operative length of stay (days)
NRI Tertile 1 (n= 94)
NRI Tertile 2 (n= 94)
NRI Tertile 3 (n= 95)
P-Value
45.4 ± 3.8 62.2 ± 12.5 21.4 ± 2.1
55.1 ± 2.9 62.84 ± 10.8 26.9 ± 1.8
71.1 ± 8.8 53.1 ± 13.1 34.2 ± 4.0
> 0.001 > 0.001 > 0.001
72 (82.8%) 76.5 ± 11.3 67.2 ± 8.8 18.3 ± 6.7 1.3 ± 0.5 762.0 (676) 48 (55.2%) 47 (71.2%) 25.0 ± 18.7
76 (86.4%) 80.8 ± 14.3 67.2 ± 10.4 18.3 ± 6.7 1.4 ± 0.5 629.0 (678) 39 (44.3%) 49 (86.0%) 24.2 ± 15.6
61 (69.3%) 82.8 ± 11.5 67.6 ± 13.3 20.6 ± 9.0 1.5 ± 0.5 287.0 (595) 56 (63.6%) 50 (80.6%) 24.4 ± 19.1
0.013 0.040 0.976 0.286 0.051 > 0.001 0.700 0.124 0.960
9( 41) Integration of Palliative Care in End of Life Care for Patients on Durable Mechanical Circulatory Support H.J. Halazun ,1 S. Pinney,1 N. Goldstein,2 L. Gelfman,2 K. Ashley,1 A. Anyanwu,1 A. Lala.1 1Cardiology, Mount Sinai Heart, New York, NY; 2Palliative Care, Mount Sinai, New York, NY. Purpose: Although outcomes for patients on durable ventricular assist device therapy (VAD) continue to improve, patients are still plagued with frequent hospitalizations and limited long-term survival. Little data exists on the optimal timing of and setting for palliative care involvement for these patients. We conducted a retrospective chart review of our single center’s experience to understand how and where VAD patients die. Methods: Charts for all patients who died after receiving a durable VAD between August 2008 and January 2015 were reviewed. Only patients who survived index hospitalization and subsequently died on VAD support were included for analysis. Data on demographic, VAD implant data, medical complications, and palliative care utilization were abstracted retrospectively. Results: A total of 62 patients died following VAD implant for either bridge to transplantation (BTT) (49 (79%)) or destination therapy (DT) (13(21%)). Of those, 37 (60%) patients died during the index hospitalization and 25 (40%) patients survived the index hospitalization but ultimately died on VAD support (BTT 66%, DT 34%). Their mean age at time of implant was 59.0 (SD 11.6) years and 84% were male. These patients lived an average of 15.6 (SD 12.4) months on VAD support. Inpatient palliative care team consultation occurred for 12 (48%) of patients at an average of 23.6 (SD 65.3) days prior to death. Causes of death were identified as intracranial bleeding (8 (32%)); pump complications (5 (20%)); sepsis (4 (16%)); multi-organ system failure (3 (12%)), respiratory failure (2 (8%)) and unknown (3 (12%)). Deaths were thought to be sudden, or unexpected, in 14 (56%) patients. Sixteen (64%) patients died in the hospital, 5 (20%) died at home and 4 (16%) died in inpatient hospice. Conclusion: The majority of VAD patients die in hospital settings, but many die at home, and die suddenly. Although palliative care consultation occurred in nearly half of these patients with durable VAD, palliative care was consulted months after VAD implant and near the end of life. There is ongoing need for earlier involvement of palliative care for this population, particularly in the outpatient setting, as a way to improve advanced care planning, symptom management, alignment of treatment preferences with treatments received, as well as caregiver bereavement. 9( 42) Hospital Readmissions After Left Ventricular Assist Device Implantation C. Heim , N. Mekkhala, M. Kondruweit, M. Weyand, R. Tandler. Department of Cardiac Surgery, University of Erlangen, Erlangen, Germany.