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The Prognostic Implications of Changes in Albumin Following LVAD Implantation
The 20th Annual Scientific Meeting
316 The Prognostic Implications of Changes in Albumin Following LVAD Implantation Dipika J. Gopal, Thomas Hanff, Jeremy Mazurek, Edward Grandin, Jessica Howard, Rhondalyn Ford-McLean, Joyce Wald, Michael Acker, Lee Goldberg, Pavan Atluri, Kenneth Margulies, J. Eduardo Rame, Edo Y. Birati; University of Pennsylvania, Philadelphia, PA
•
HFSA
S109
Purpose: Rotational thromboelastometry (ROTEM), a method for hemostasis testing in whole blood, has been used to manage and adjust anti-coagulation therapy in post VAD implant patients. Performing ROTEM prior to implant may shed light on important hemostatic characteristics in patients that develop pump thrombosis (PT) post VAD implantation. Methods: All VAD implantations at our institution between 2008 through 2015 were included in the analysis. Suspected PT was defined as a pump-related malfunction and hemolysis and definitive PT required visualized thrombus at the time of explant. A subset of patients underwent ROTEM prior to postimplant. The patients’ EXTEM CT (latency time of clot formation once start reagent has been added to a patient’s blood) was measured and analyzed. Results: 139 patients were implanted during the study time (21% female). 28 patients had suspected or definitive pump thrombosis (25%). There were no significant differences found in mean age, gender, etiology of heart failure, or medications (see Table 1). Patients with PT were more likely to have public insurance (P = .03). There was no significant difference in patients’ pre-implant EXTEM CT between non-PT and PT (mean 56 and 62, respectively, P = .10). Using Friedman’s ANOVA, the ROTEM EXTEM CT value increased over the pre-implant through 3 month post-implant interval (P = .006, n = 15). This was not looked at separately for patients who experienced a thrombotic event vs patients who did not due to low sample size. Conclusion: Other than insurance type, there are no easily identifiable clinical or pre-implant risk factors associated with PT. Furthermore, there was no significant difference preimplant ROTEM EXTEM CT between the two groups. It is notable that there is a significant increase of patients’ CT over the 3 month interval, regardless of a diagnosis of thrombosis. Further studies are needed to explore the alterations in hemostatics in VAD patients who experience PT.
Mechanical assist devices have emerged as an established therapeutic option for patients with end-stage heart failure. Recognizing patients who will do poorly postimplant is essential to optimize patient management and outcomes. Hypothesis: Since albumin level may reflect nutritional status, improvement in albumin from pre to postimplant may be an important prognostic indicator in patients treated with continuous flow left ventricular assist devices (cfLVAD). Methods: In this retrospective single center study we included all patients who underwent cfLVAD implantation (HeartMate II and HeartWare HVAD) at an academic center from 2008 to 2014. We excluded patients who died, were transplanted, or hospitalized during the first 3 months post-implant. Pre-implant albumin was defined as the albumin closest to but prior to the day of implant and not more than 30 days before surgery. Hypoalbuminemia was defined as <3.5 g/dL and normal albumin as ≥3.5 g/dL. We tested for association with clinical outcomes post cfLVAD including 1 and 2-year survival and time to first post-implant hospitalization. Results: From 202 total patients (80% male, mean age 56 ± 16 years), 145 were included for survival analysis and 93 were included for hospitalization analysis. The mean albumin at pre-implant, 3-months post-implant and 6-months post-implant was 3.5 ± 0.6 g/ dL, 3.6 ± 0.7 g/dL, and 3.9 ± 0.5 g/dL, respectively (P < .01). Hypoalbuminemia at 3-months post-implant correlated with increased mortality (HR 2.19 CI 1.20–4.01, P = .01) and reduced time to first post-implant hospital admission (HR 2.36 CI 1.37–4.06, P < .01). Decrease in albumin from pre-implant to 3-months post-implant was also associated with increased mortality (HR 2.93 CI 1.57–5.44, P < .01) and shorter time to first postimplant hospital admission (HR 1.70 CI 1.03–2.81, P = .04). Subgroup analysis revealed that those who started with hypoalbuminemia but had normal albumin values at 3-months post-implant had improved survival and longer time to first post-implant hospitalization than those who had persistent hypoalbuminemia, decrease in albumin over time and even those who maintained normal albumin throughout. Conclusions: Our study is the first to demonstrate the importance of post-implant albumin as well as the changes in albumin from pre- to post-implant on the prognosis of cfLVAD patients. This suggests that regardless of pre-implant albumin, therapeutic intervention to improve albumin or nutritional status post-implant may prevent hospitalizations and improve outcomes.
318 Cognitive Improvement Post-Placement of Left Ventricular Assist Device Mark R. Bonnell, Drake Steed, Thomas Schwann, George Moukarbel, Samer Khoury, Michelle Hudson, Allison Meyers-Fabian, Mary Haines; University of Toledo Medical Center, Toledo, OH
317 Clinical and Hemostatic Characteristics of Patients With Ventricular Assist Device Thrombosis Kristina Quinn1, Demetrios Doukas1, Neelam Balasubramanian1, Tania Torres2, Jeanine Walenga1, Erin Coglianese1; 1Loyola University Medical Center, Maywood, IL; 2Loyola University Stritch School of Medicine, Maywood, IL
Background: Either as bridge to transplant or destination therapy, left ventricular assist devices (LVADs) serve many patients with advanced heart failure (AHF). Systemic dysfunction, including extended periods of cerebral hypoperfusion, places patients with AHF at increased risk for cognitive decline. Despite reports of improvement in multiple body systems following LVAD placement, including increased cerebral perfusion, research examining longitudinal outcomes of cognition is sparse. In prior research (n = 12),
316 The Prognostic Implications of Changes in Albumin Following LVAD Implantation Dipika J. Gopal, Thomas Hanff, Jeremy Mazurek, Edward Grandin, Jessica Howard, Rhondalyn Ford-McLean, Joyce Wald, Michael Acker, Lee Goldberg, Pavan Atluri, Kenneth Margulies, J. Eduardo Rame, Edo Y. Birati; University of Pennsylvania, Philadelphia, PA
•
HFSA
S109
Purpose: Rotational thromboelastometry (ROTEM), a method for hemostasis testing in whole blood, has been used to manage and adjust anti-coagulation therapy in post VAD implant patients. Performing ROTEM prior to implant may shed light on important hemostatic characteristics in patients that develop pump thrombosis (PT) post VAD implantation. Methods: All VAD implantations at our institution between 2008 through 2015 were included in the analysis. Suspected PT was defined as a pump-related malfunction and hemolysis and definitive PT required visualized thrombus at the time of explant. A subset of patients underwent ROTEM prior to postimplant. The patients’ EXTEM CT (latency time of clot formation once start reagent has been added to a patient’s blood) was measured and analyzed. Results: 139 patients were implanted during the study time (21% female). 28 patients had suspected or definitive pump thrombosis (25%). There were no significant differences found in mean age, gender, etiology of heart failure, or medications (see Table 1). Patients with PT were more likely to have public insurance (P = .03). There was no significant difference in patients’ pre-implant EXTEM CT between non-PT and PT (mean 56 and 62, respectively, P = .10). Using Friedman’s ANOVA, the ROTEM EXTEM CT value increased over the pre-implant through 3 month post-implant interval (P = .006, n = 15). This was not looked at separately for patients who experienced a thrombotic event vs patients who did not due to low sample size. Conclusion: Other than insurance type, there are no easily identifiable clinical or pre-implant risk factors associated with PT. Furthermore, there was no significant difference preimplant ROTEM EXTEM CT between the two groups. It is notable that there is a significant increase of patients’ CT over the 3 month interval, regardless of a diagnosis of thrombosis. Further studies are needed to explore the alterations in hemostatics in VAD patients who experience PT.
Mechanical assist devices have emerged as an established therapeutic option for patients with end-stage heart failure. Recognizing patients who will do poorly postimplant is essential to optimize patient management and outcomes. Hypothesis: Since albumin level may reflect nutritional status, improvement in albumin from pre to postimplant may be an important prognostic indicator in patients treated with continuous flow left ventricular assist devices (cfLVAD). Methods: In this retrospective single center study we included all patients who underwent cfLVAD implantation (HeartMate II and HeartWare HVAD) at an academic center from 2008 to 2014. We excluded patients who died, were transplanted, or hospitalized during the first 3 months post-implant. Pre-implant albumin was defined as the albumin closest to but prior to the day of implant and not more than 30 days before surgery. Hypoalbuminemia was defined as <3.5 g/dL and normal albumin as ≥3.5 g/dL. We tested for association with clinical outcomes post cfLVAD including 1 and 2-year survival and time to first post-implant hospitalization. Results: From 202 total patients (80% male, mean age 56 ± 16 years), 145 were included for survival analysis and 93 were included for hospitalization analysis. The mean albumin at pre-implant, 3-months post-implant and 6-months post-implant was 3.5 ± 0.6 g/ dL, 3.6 ± 0.7 g/dL, and 3.9 ± 0.5 g/dL, respectively (P < .01). Hypoalbuminemia at 3-months post-implant correlated with increased mortality (HR 2.19 CI 1.20–4.01, P = .01) and reduced time to first post-implant hospital admission (HR 2.36 CI 1.37–4.06, P < .01). Decrease in albumin from pre-implant to 3-months post-implant was also associated with increased mortality (HR 2.93 CI 1.57–5.44, P < .01) and shorter time to first postimplant hospital admission (HR 1.70 CI 1.03–2.81, P = .04). Subgroup analysis revealed that those who started with hypoalbuminemia but had normal albumin values at 3-months post-implant had improved survival and longer time to first post-implant hospitalization than those who had persistent hypoalbuminemia, decrease in albumin over time and even those who maintained normal albumin throughout. Conclusions: Our study is the first to demonstrate the importance of post-implant albumin as well as the changes in albumin from pre- to post-implant on the prognosis of cfLVAD patients. This suggests that regardless of pre-implant albumin, therapeutic intervention to improve albumin or nutritional status post-implant may prevent hospitalizations and improve outcomes.
318 Cognitive Improvement Post-Placement of Left Ventricular Assist Device Mark R. Bonnell, Drake Steed, Thomas Schwann, George Moukarbel, Samer Khoury, Michelle Hudson, Allison Meyers-Fabian, Mary Haines; University of Toledo Medical Center, Toledo, OH
317 Clinical and Hemostatic Characteristics of Patients With Ventricular Assist Device Thrombosis Kristina Quinn1, Demetrios Doukas1, Neelam Balasubramanian1, Tania Torres2, Jeanine Walenga1, Erin Coglianese1; 1Loyola University Medical Center, Maywood, IL; 2Loyola University Stritch School of Medicine, Maywood, IL
Background: Either as bridge to transplant or destination therapy, left ventricular assist devices (LVADs) serve many patients with advanced heart failure (AHF). Systemic dysfunction, including extended periods of cerebral hypoperfusion, places patients with AHF at increased risk for cognitive decline. Despite reports of improvement in multiple body systems following LVAD placement, including increased cerebral perfusion, research examining longitudinal outcomes of cognition is sparse. In prior research (n = 12),