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Value of Preoperative Pectoral Muscle Index as a Predictor of Outcomes after LVAD Implantation
S346
The Journal of Heart and Lung Transplantation, Vol 39, No 4S, April 2020
Purpose: Right ventricular failure (RVF) is one of the major complications after LVAD implantation. In acute phase after LVAD implantation, inhalation of nitric oxide (NO) and mechanical respiratory support and extubation causes hemodynamic changes on right heart dramatically. Although perioperative management is crucial to prevent RVF, there was no study which analyzed the impact of NO, mechanical respiratory support and extubation on hemodynamics of right heart in detail. Methods: Between December 2014 and September 2018, consecutive 102 patients underwent LVADs implantation in Osaka University Hospital. Patients below 18 years were excluded. Patients with right ventricular assist device support, and/or tracheostomy without trying of extubation after LVAD implantation were also excluded. Finally, 75 patients were included in this study (mean age, 45 § 14 years; 30% were women). We used 5 different types of LVADs. We assessed the perioperative course of central venous pressure (CVP), pulmonary vascular resistance (PVR), and cardiac index (CI) before and after discontinuation of NO and extubation. Results: Mean duration of NO inhalation was 2.0(0-3.3) days and final concentration of NO was 5ppm. The changes of CVP and CI before and after discontinuation of NO were not significantly (CVP: 10.0§ 2.7 to 10§2.7 mmHg, p=0.436, CI: 2.8§0.6 to 2.6§0.4 l/min/m2, p=0.999). Mean duration of intubation was 2.7(1.8-6.2) days. Just before extubation, respiratory rate was 17§4rpm and PaO2/FiO2 ratio was 341§71 under 5 cmH20 of positive end-expiratory pressure. The changes of CVP, PVR and CI before and after extubation were significantly (CVP: 9.1§2.9 to 8.2§3.0 mmHg, p=0.001, PVR: 1.1§0.4 to 1.2§0.5 wood, p=0.014, CI: 2.8§0.6 to 3.0§0.6 l/min/m2, p=0.004). Furthermore, patients with elevated CVP(310mmHg, n=31) also increased their CI significantly after extubation (CI:2.9§0.5 to 3.1§ 0.6 l/min/m2, p=0.007). Conclusion: Among adult patients with LVAD, discontinuation of NO inhalation caused minor decrease of CI but not significant. Extubation improves CI even patients with elevated CVP, who are higher risk for suffering from RVF. These analysis of hemodynamic changes imply that after respiratory condition become stable, extubation could be one important choice to improve hemodynamics even in patients with higher risk for RVF.
(863) Value of Preoperative Pectoral Muscle Index as a Predictor of Outcomes after LVAD Implantation S. George, M.O. Crespo, B.L. Fortson, C.L. Eshelbrenner, A. El Elbanayosy, D.A. Horstmanshof and J.W. Long Advanced Cardiac Care, INTEGRIS Baptist Medical Center, Oklahoma City, OK. Purpose: Cardiac cachexia with associated sarcopenia and frailty has been associated with adverse outcomes after placement of a durable left ventricular assist device (LVAD). The purpose of this study is to examine whether the pectoralis muscle index (PMI) measured from preoperative CT scans of the chest will predict outcomes after LVAD implantation. Methods: We retrospectively reviewed preop CT scans of the chest on 76 LVAD patients implanted between 1/2017 and 8/2018. The axial CT slice with the greatest pectoralis area at or near the level of the sternoclavicular joint was identified, and PMI was calculated by dividing the measured pectoralis area in cm by the patient’s height in m2. Kruskal-Wallis test was used to compare length of stay, Fisher’s Exact test to assess mortality and readmission rates. The overall survival was by Kaplan-Meier estimate, and the Log-Rank test was used to compare the survival curves. Results: A total of 76 LVAD patients were included. Subjects were divided into low, medium, and high PMI terciles (Table 1). 30/60/ 90 day mortality, length of stay, and 30-day readmission rate trended higher in patients with the lowest PMI, although the differences did not reach statistical significance. Overall mortality (Figure 1) also clearly trended by PMI tercile but did not reach statistical significance in this population.
Conclusion: Preoperative PMI may be a predictor of outcomes post LVAD implant independently, and value in our center might be better defined with a larger sample size. The value of PMI could potentially be enhanced by combination with other assessments of sarcopenia, such as psoas muscle area.
(864) Long-Term Outcomes of Heartware Left Ventricular Assist Device Decommissioning for Myocardial Recovery L. Wang, A. Woods, N. Robinson-Smith, S. Tovey, A. McDiarmid, G. Parry, S. Schueler and G. MacGowan Cardiothoracic Service, Freeman Hospital, Newcastle upon Tyne, United Kingdom. Purpose: Left ventricular assist device (LVAD) decommissioning reduces the risks associated with long-term LVAD support without subjecting patients to a major explantation operation. However, the long-term outcomes of this strategy are not known. Methods: Our unit’s LVAD database was reviewed to identify patients who underwent LVAD decommissioning for myocardial recovery from 2009 to 2019. Friedman test was performed to compare left ventricle (LV) function grades over time and repeated measures ANOVA for ejection fraction (EF). Kaplan-Meier analysis was conducted to compare the survival of these patients with the LVAD bridged to transplant and all other LVAD patients. Results: Among the 254 adult LVAD patients, 11 (4.3%) underwent decommissioning for myocardial recovery after assessment at low flow. The median support duration was 940 (IQR 646-1078) days and median follow-up duration 1425 (IQR 776-1774) days. 3 patients (27.3%) died during follow-up, 1 due to heart failure and 2 due to sepsis. 4 patients (36.4%) had LVAD explantation subsequently due to recurrent sepsis. This group’s survival was comparable to that of the LVAD bridged to transplant group (p=0.7) and significantly better than that of the all other LVAD group (p=0.0015) (Figure 1). However, after decommissioning, their LV function gradually deteriorated (Figure 2). Conclusion: Selected patients with myocardial recovery would benefit from LVAD decommissioning with favourable long-term outcomes. However, they still face the potential risk of systemic infection and need to be regularly followed up for LV function monitoring and medical therapy optimisation.
The Journal of Heart and Lung Transplantation, Vol 39, No 4S, April 2020
Purpose: Right ventricular failure (RVF) is one of the major complications after LVAD implantation. In acute phase after LVAD implantation, inhalation of nitric oxide (NO) and mechanical respiratory support and extubation causes hemodynamic changes on right heart dramatically. Although perioperative management is crucial to prevent RVF, there was no study which analyzed the impact of NO, mechanical respiratory support and extubation on hemodynamics of right heart in detail. Methods: Between December 2014 and September 2018, consecutive 102 patients underwent LVADs implantation in Osaka University Hospital. Patients below 18 years were excluded. Patients with right ventricular assist device support, and/or tracheostomy without trying of extubation after LVAD implantation were also excluded. Finally, 75 patients were included in this study (mean age, 45 § 14 years; 30% were women). We used 5 different types of LVADs. We assessed the perioperative course of central venous pressure (CVP), pulmonary vascular resistance (PVR), and cardiac index (CI) before and after discontinuation of NO and extubation. Results: Mean duration of NO inhalation was 2.0(0-3.3) days and final concentration of NO was 5ppm. The changes of CVP and CI before and after discontinuation of NO were not significantly (CVP: 10.0§ 2.7 to 10§2.7 mmHg, p=0.436, CI: 2.8§0.6 to 2.6§0.4 l/min/m2, p=0.999). Mean duration of intubation was 2.7(1.8-6.2) days. Just before extubation, respiratory rate was 17§4rpm and PaO2/FiO2 ratio was 341§71 under 5 cmH20 of positive end-expiratory pressure. The changes of CVP, PVR and CI before and after extubation were significantly (CVP: 9.1§2.9 to 8.2§3.0 mmHg, p=0.001, PVR: 1.1§0.4 to 1.2§0.5 wood, p=0.014, CI: 2.8§0.6 to 3.0§0.6 l/min/m2, p=0.004). Furthermore, patients with elevated CVP(310mmHg, n=31) also increased their CI significantly after extubation (CI:2.9§0.5 to 3.1§ 0.6 l/min/m2, p=0.007). Conclusion: Among adult patients with LVAD, discontinuation of NO inhalation caused minor decrease of CI but not significant. Extubation improves CI even patients with elevated CVP, who are higher risk for suffering from RVF. These analysis of hemodynamic changes imply that after respiratory condition become stable, extubation could be one important choice to improve hemodynamics even in patients with higher risk for RVF.
(863) Value of Preoperative Pectoral Muscle Index as a Predictor of Outcomes after LVAD Implantation S. George, M.O. Crespo, B.L. Fortson, C.L. Eshelbrenner, A. El Elbanayosy, D.A. Horstmanshof and J.W. Long Advanced Cardiac Care, INTEGRIS Baptist Medical Center, Oklahoma City, OK. Purpose: Cardiac cachexia with associated sarcopenia and frailty has been associated with adverse outcomes after placement of a durable left ventricular assist device (LVAD). The purpose of this study is to examine whether the pectoralis muscle index (PMI) measured from preoperative CT scans of the chest will predict outcomes after LVAD implantation. Methods: We retrospectively reviewed preop CT scans of the chest on 76 LVAD patients implanted between 1/2017 and 8/2018. The axial CT slice with the greatest pectoralis area at or near the level of the sternoclavicular joint was identified, and PMI was calculated by dividing the measured pectoralis area in cm by the patient’s height in m2. Kruskal-Wallis test was used to compare length of stay, Fisher’s Exact test to assess mortality and readmission rates. The overall survival was by Kaplan-Meier estimate, and the Log-Rank test was used to compare the survival curves. Results: A total of 76 LVAD patients were included. Subjects were divided into low, medium, and high PMI terciles (Table 1). 30/60/ 90 day mortality, length of stay, and 30-day readmission rate trended higher in patients with the lowest PMI, although the differences did not reach statistical significance. Overall mortality (Figure 1) also clearly trended by PMI tercile but did not reach statistical significance in this population.
Conclusion: Preoperative PMI may be a predictor of outcomes post LVAD implant independently, and value in our center might be better defined with a larger sample size. The value of PMI could potentially be enhanced by combination with other assessments of sarcopenia, such as psoas muscle area.
(864) Long-Term Outcomes of Heartware Left Ventricular Assist Device Decommissioning for Myocardial Recovery L. Wang, A. Woods, N. Robinson-Smith, S. Tovey, A. McDiarmid, G. Parry, S. Schueler and G. MacGowan Cardiothoracic Service, Freeman Hospital, Newcastle upon Tyne, United Kingdom. Purpose: Left ventricular assist device (LVAD) decommissioning reduces the risks associated with long-term LVAD support without subjecting patients to a major explantation operation. However, the long-term outcomes of this strategy are not known. Methods: Our unit’s LVAD database was reviewed to identify patients who underwent LVAD decommissioning for myocardial recovery from 2009 to 2019. Friedman test was performed to compare left ventricle (LV) function grades over time and repeated measures ANOVA for ejection fraction (EF). Kaplan-Meier analysis was conducted to compare the survival of these patients with the LVAD bridged to transplant and all other LVAD patients. Results: Among the 254 adult LVAD patients, 11 (4.3%) underwent decommissioning for myocardial recovery after assessment at low flow. The median support duration was 940 (IQR 646-1078) days and median follow-up duration 1425 (IQR 776-1774) days. 3 patients (27.3%) died during follow-up, 1 due to heart failure and 2 due to sepsis. 4 patients (36.4%) had LVAD explantation subsequently due to recurrent sepsis. This group’s survival was comparable to that of the LVAD bridged to transplant group (p=0.7) and significantly better than that of the all other LVAD group (p=0.0015) (Figure 1). However, after decommissioning, their LV function gradually deteriorated (Figure 2). Conclusion: Selected patients with myocardial recovery would benefit from LVAD decommissioning with favourable long-term outcomes. However, they still face the potential risk of systemic infection and need to be regularly followed up for LV function monitoring and medical therapy optimisation.