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Vasoactive-Inotropic Score Is Associated with In-Hospital Mortality in Continuous Flow Left Ventricular Assist Device Patients
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The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017 3( 55)
3( 54) Vasoactive-Inotropic Score Is Associated with In-Hospital Mortality in Continuous Flow Left Ventricular Assist Device Patients J. Han ,1 H. Takayama,1 P.A. Kurlansky,1 A.R. Garan,2 M. Yuzefpolskaya,2 V.K. Topkara,2 P.C. Colombo,2 Y. Naka,1 K. Takeda.1 1Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY; 2Division of Cardiology, Columbia University Medical Center, New York, NY. Purpose: Vasoactive-inotropic score (VIS) has been associated with outcomes in pediatric cardiac surgery patients, but its use in durable continuous flow left ventricular assist device (LVAD) patients is unknown. The purpose of this study is to evaluate the utility of VIS in predicting in-hospital mortality and long-term survival in LVAD patients. Methods: A total of 431 patients underwent isolated LVAD implantation from May 2004 to December 2015. VIS was calculated as dopamine + dobutamine + 100 × milrinone + 100 × epinephrine + 100 × norepinephrine + 100 × epinephrine (all in μ g/kg/min) + 10000 × vasopressin (U/kg/min) at time of intensive care unit admission following surgery. We evaluated in-hospital mortality, 3-year on-device survival, and association with VIS following orthotopic heart transplant. Results: The study population had mean age of 58 ± 13 years, 82.4% were male, and 33.7% were destination therapy. Univariate linear regression showed each unit increase age was associated with an increase of 0.11 in VIS (95% CI: [0.021, 0.195], p = 0.015) and each unit of BMI was associated with decrease of 0.59 in VIS (95% CI: [-0.849, -0.330], p < 0.001), but no difference in pre-operative inotrope or vasopressor use. VIS increased by 0.060 (95% CI: [0.032, 0.087], p < 0.001) for each additional minute of cardiopulmonary bypass time. Multivariate logistic regression showed that VIS is an independent predictor of in-hospital mortality with an odds ratio of 1.04 for each unit increase in VIS (95% CI: [1.002, 1.087], p = 0.037). Multivariate Cox proportional model showed that VIS did not affect 3-year on-device survival (HR 1.019, 95% CI: [0.998, 1.040], p = 0.071). Post-transplant survival was not associated with VIS at time of LVAD implantation. Conclusion: Elevated VIS at time of LVAD implantation is associated with increased incidence of in-hospital mortality but does not affect long-term on-device survival or post-transplant outcomes.
The Duration of Inotropic Support and Survival After Left Ventricular Assist Device E. Grandin ,1 D. Mooney,1 K. Kennedy,2 M.S. Kiernan,3 R.D. Kociol,1 J.J. Teuteberg,4 F.D. Pagani,5 A.C. Gaffey,6 P. Atluri,7 E.Y. Birati,8 S. Myers,9 D. Naftel,9 G. Oliveira,10 K.E. Simpson,11 R.W. Yeh,1 J.K. Kirklin,12 R.L. Kormos,13 J. Rame.8 1Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 2Mid America Heart Institute, St. Luke's Hospital, Kansas City, MO; 3Division of Cardiovascular Medicine, Tufts Medical Center, Boston, MA; 4Division of Cardiovascular Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; 5Division of Cardiovascular Surgery, University of Michigan, Ann Arbor, MI; 6Division of Cardiovascular Surgery, Hospital of the University of Pennyslvania, Philadelphia, PA; 7Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; 8Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; 9INTERMACS, University of Alabama at Birmingham, Birmingham, AL; 10Division of Cardiovascular Medicine, University Hospitals Case Medical Center, Cleveland, OH; 11Division of Pediatric Cardiology, St. Louis Children’s Hospital, St. Louis, MO; 12Division of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, AL; 13Division of Cardiovascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. Purpose: Right heart failure (RHF) after continuous-flow left ventricular assist device (cfLVAD) has typically been defined as the need for right ventricular assist device (RVAD) or prolonged inotropic support (IS), usually ≥ 14 days. A graded definition of RHF has been proposed, and prior singlecenter work revealed a strong relationship between the duration of IS or early RVAD and clinical outcomes. We aimed to characterize survival after cfLVAD based on the need for RVAD or duration of IS. Methods: Patients from the INTERMACS registry implanted with a cfLVAD from 6/06-6/15 (n= 15579) were stratified at 1 month post LVAD by early RVAD or the duration of IS. Patients were excluded for prior VAD, concomitant durable RVAD, atypical LVAD cannulation, or death or transplant within 1 month. Early RVAD was defined as either concomitant temporary RVAD or delayed RVAD within 1 month. Patients who did not receive RVAD were categorized by the duration of IS: < 1 wk, 1-2 wks, 2-4 wks, and > 4 wks/ ongoing. We analyzed conditional survival starting 1 month after LVAD with censoring for heart transplant or device explant. Results: The final cohort consisted of 11,665 patients: 5694 (48.8%) required IS < 1 wk, 3761 (32.2%) IS 1-2 wks, 1178 (10.0%) IS 2-4 wks, 547 (4.7%) IS 4 wks/ongoing, and 485 (4.2%) early RVAD. Median follow up was 14 months (IQR: 8-27). Need for early RVAD and the duration of IS were strongly associated with survival, which persisted after adjustment for other covariates (Figure). Among patients without early major bleeding or infection, other potential causes of IS, the association was similar: IS < 1wk (referent), IS 1-2 wks adj-HR 1.21 (p= 0.002), IS 2-4 wks adj-HR 1.50 (p< 0.0001), IS > 4wks/ ongoing adj-HR 2.39 (p< 0.0001), and early RVAD adj-HR 2.03 (p< 0.0001). Conclusion: We demonstrate a significant incremental relationship between the duration of post-implant IS and survival after LVAD. These findings strongly support a graded definition of RHF and have implications for revising the thresholds of IS used to define RHF severity.
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017 3( 55)
3( 54) Vasoactive-Inotropic Score Is Associated with In-Hospital Mortality in Continuous Flow Left Ventricular Assist Device Patients J. Han ,1 H. Takayama,1 P.A. Kurlansky,1 A.R. Garan,2 M. Yuzefpolskaya,2 V.K. Topkara,2 P.C. Colombo,2 Y. Naka,1 K. Takeda.1 1Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY; 2Division of Cardiology, Columbia University Medical Center, New York, NY. Purpose: Vasoactive-inotropic score (VIS) has been associated with outcomes in pediatric cardiac surgery patients, but its use in durable continuous flow left ventricular assist device (LVAD) patients is unknown. The purpose of this study is to evaluate the utility of VIS in predicting in-hospital mortality and long-term survival in LVAD patients. Methods: A total of 431 patients underwent isolated LVAD implantation from May 2004 to December 2015. VIS was calculated as dopamine + dobutamine + 100 × milrinone + 100 × epinephrine + 100 × norepinephrine + 100 × epinephrine (all in μ g/kg/min) + 10000 × vasopressin (U/kg/min) at time of intensive care unit admission following surgery. We evaluated in-hospital mortality, 3-year on-device survival, and association with VIS following orthotopic heart transplant. Results: The study population had mean age of 58 ± 13 years, 82.4% were male, and 33.7% were destination therapy. Univariate linear regression showed each unit increase age was associated with an increase of 0.11 in VIS (95% CI: [0.021, 0.195], p = 0.015) and each unit of BMI was associated with decrease of 0.59 in VIS (95% CI: [-0.849, -0.330], p < 0.001), but no difference in pre-operative inotrope or vasopressor use. VIS increased by 0.060 (95% CI: [0.032, 0.087], p < 0.001) for each additional minute of cardiopulmonary bypass time. Multivariate logistic regression showed that VIS is an independent predictor of in-hospital mortality with an odds ratio of 1.04 for each unit increase in VIS (95% CI: [1.002, 1.087], p = 0.037). Multivariate Cox proportional model showed that VIS did not affect 3-year on-device survival (HR 1.019, 95% CI: [0.998, 1.040], p = 0.071). Post-transplant survival was not associated with VIS at time of LVAD implantation. Conclusion: Elevated VIS at time of LVAD implantation is associated with increased incidence of in-hospital mortality but does not affect long-term on-device survival or post-transplant outcomes.
The Duration of Inotropic Support and Survival After Left Ventricular Assist Device E. Grandin ,1 D. Mooney,1 K. Kennedy,2 M.S. Kiernan,3 R.D. Kociol,1 J.J. Teuteberg,4 F.D. Pagani,5 A.C. Gaffey,6 P. Atluri,7 E.Y. Birati,8 S. Myers,9 D. Naftel,9 G. Oliveira,10 K.E. Simpson,11 R.W. Yeh,1 J.K. Kirklin,12 R.L. Kormos,13 J. Rame.8 1Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA; 2Mid America Heart Institute, St. Luke's Hospital, Kansas City, MO; 3Division of Cardiovascular Medicine, Tufts Medical Center, Boston, MA; 4Division of Cardiovascular Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA; 5Division of Cardiovascular Surgery, University of Michigan, Ann Arbor, MI; 6Division of Cardiovascular Surgery, Hospital of the University of Pennyslvania, Philadelphia, PA; 7Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; 8Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA; 9INTERMACS, University of Alabama at Birmingham, Birmingham, AL; 10Division of Cardiovascular Medicine, University Hospitals Case Medical Center, Cleveland, OH; 11Division of Pediatric Cardiology, St. Louis Children’s Hospital, St. Louis, MO; 12Division of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, AL; 13Division of Cardiovascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. Purpose: Right heart failure (RHF) after continuous-flow left ventricular assist device (cfLVAD) has typically been defined as the need for right ventricular assist device (RVAD) or prolonged inotropic support (IS), usually ≥ 14 days. A graded definition of RHF has been proposed, and prior singlecenter work revealed a strong relationship between the duration of IS or early RVAD and clinical outcomes. We aimed to characterize survival after cfLVAD based on the need for RVAD or duration of IS. Methods: Patients from the INTERMACS registry implanted with a cfLVAD from 6/06-6/15 (n= 15579) were stratified at 1 month post LVAD by early RVAD or the duration of IS. Patients were excluded for prior VAD, concomitant durable RVAD, atypical LVAD cannulation, or death or transplant within 1 month. Early RVAD was defined as either concomitant temporary RVAD or delayed RVAD within 1 month. Patients who did not receive RVAD were categorized by the duration of IS: < 1 wk, 1-2 wks, 2-4 wks, and > 4 wks/ ongoing. We analyzed conditional survival starting 1 month after LVAD with censoring for heart transplant or device explant. Results: The final cohort consisted of 11,665 patients: 5694 (48.8%) required IS < 1 wk, 3761 (32.2%) IS 1-2 wks, 1178 (10.0%) IS 2-4 wks, 547 (4.7%) IS 4 wks/ongoing, and 485 (4.2%) early RVAD. Median follow up was 14 months (IQR: 8-27). Need for early RVAD and the duration of IS were strongly associated with survival, which persisted after adjustment for other covariates (Figure). Among patients without early major bleeding or infection, other potential causes of IS, the association was similar: IS < 1wk (referent), IS 1-2 wks adj-HR 1.21 (p= 0.002), IS 2-4 wks adj-HR 1.50 (p< 0.0001), IS > 4wks/ ongoing adj-HR 2.39 (p< 0.0001), and early RVAD adj-HR 2.03 (p< 0.0001). Conclusion: We demonstrate a significant incremental relationship between the duration of post-implant IS and survival after LVAD. These findings strongly support a graded definition of RHF and have implications for revising the thresholds of IS used to define RHF severity.