Predicting Outcomes in Patients Requiring Extracorporeal Membrane Oxygenation

Predicting Outcomes in Patients Requiring Extracorporeal Membrane Oxygenation

S330 The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017 PCI. We report our experience using emergency extracorporeal membrano...

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The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017

PCI. We report our experience using emergency extracorporeal membranous oxygenation (ECMO) support for arrest and cardiogenic shock due to acute MI during or after PCI in the cath lab. Methods: A prospective database of ECMO cases from October 2012 through July 2016 was retrospectively reviewed. Out of 326 total trials of ECMO performed at our institution during this time, N= 39 (12%) patients required ECMO support after acute MI and were divided into the following three groups: those placed on ECMO after arresting in the cardiac catheterization lab while actively undergoing PCI for acute MI, those transferred from another facility on ECMO after acute MI and those placed on ECMO later in their hospital course following successful PCI. Results: Mean age was 58 ± 12 years, and 31 (78%) were male. Percutaneous venoarterial access was obtained in all patients. An IABP was also placed in 12 (30%) patients. Mean time for all patients on ECMO support was 5.9 ± 3.5 days. A total of 26 (67%) patients survived ECMO support and 16 patients (41%) survived to hospital discharge. Survival to discharge for patients who arrested in the cath lab during PCI comapred to those transfered from another hospital and those who arrested following EMCO insertion was 42%, 50% and 20% respectively. 30 day survival after hospital discharge was 88%. Conclusion: Surivial with manual CPR following cardiocirculatory arrest after acute MI is abysmal. A major advantage of ECMO is that this system allows PCI to be completed if the arrest occurs in the cath lab, whereas manual chest compressions interrupt these procedures. In patients with cardiocirculatory arrest following acute MI ECMO should be preferred to manual CPR and should be initiated early to increase the likelihood of hospital discharge and short-term survival. 1( 012) Employment Status and Wait-List Outcomes in Patients Bridged with Left Ventricular Assist Devices L. Meece , S.G. Al-Kindi, C. Bianco, B. Dhakal, M. Ginwalla, C. Elamm, G.H. Oliveira.  Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH. Purpose: Socioeconomic status impacts outcomes in advanced heart failure therapies. It is unknown if employment status is associated with outcomes in left ventricular assist devices (LVAD). Methods: We identified all adults listed for heart transplantation with continuous flow LVAD (heartmate II or heartware), from 2008 to 2015 with a known employment status at listing. We followed patients from listing until mortality or delisting for deterioration while on the wait-list. Results: A total of 4690 patients were included in this analysis: Mean age of 53.2 + 11.8, 80% male, 65% caucasian, 30% status 1A. Only 351 (8%) were working for income at the time of listing. Compared with employed patients, unemployed patients had similar age (p= 0.29), less likely to be 1A (31% vs 23%, p= 0.001), caucasian (79% vs 64%, p< 0.001), female (21% vs 15%, p= 0.004). At a median of 176 days on the waitlist, 234 (5%) died and 285 (6%) were delisted. After multiple adjustments, unemployment status was associated with increased waitlist mortality or delisting (HR 1.39 [1.07-1.80], p= 0.013). Conclusion: Less than 1 in 10 of patients bridged to transplantation with LVAD are employed for income. Unemployment status had higher rates of waitlist mortality or delisting, independently of established risk factors.

1( 013) Depression in Patients Undergoing Left Ventricular Assist Device Implantation S. Lundgren , E. Raichlin, A. Selim, B. Lowes, R. Zolty, M. Moulton, J. Um, C. Poon.  University of Nebraska Medical Center, Omaha, NE. Purpose: Depression is a common comorbidity in heart failure patients and is associated with poor quality of life, increased risk of mortality, and hospitalization in heart failure patients. The aim of this study was to identify the prevalence of depression in LVAD candidates and assess its effect on outcomes after LVAD implantation. Methods: Depression and other psychiatric conditions were assessed through a clinical interview by a psychologist prior to LVAD implantation. Patients also completed the Beck Depression Inventory II (BDI-II). Based on the clinical interview report, patients were divided into two groups: Depressed (DEP) and not depressed (NDEP). Results: Out of a total of 264 patients, DEP group comprised 74 (30%) patients of the total cohort. BDI-II score was 16±10 in the DEP group and 8±6 in the NDEP group (p< 0.001). DEP was associated with female gender (28% vs.16%, p= 0.03), higher BMI (32 ±7 vs. 29±5; p= 0.03), lower mean PWP (22±10vs.25±9, p= 0.05) and PAP (34±12 vs.38±1, p=  0.04) and lower E/E’ (25± vs.18±, p= 0.034). DEP patients more often had a history of alcohol use (34% vs. 22%, p= 0.05), concomitant anxiety (43% vs. 19%, p< 0.001) and other major psychiatric diagnosis (15% vs. 4%, p=  0.005). There was no difference between the groups in the length of initial hospital stay, the number of hospital readmissions, and the prevalence of post-LVAD complications such as stroke, pump thrombosis, bleeding or infection. One year after LVAD implantation heart transplant rate was (32% vs.28%, p=  0.96, log-rank) and mortality was (74% vs. 82%, p= 0.66, log rank)) in the DEP and NDEP groups respectively. (Figure 1). Conclusion: Depression is a common comorbidity in patients evaluated for LVAD implantation, however, it does not affect major medical outcomes after LVAD implantation.

1( 014) Predicting Outcomes in Patients Requiring Extracorporeal Membrane Oxygenation S. Wu ,1 M. Fong,2 L. Saxon,2 G. Fox,3 L. Wiggins,4 A. Hackmann.4  1Internal Medicine, University of Southern California, Los Angeles, CA; 2Cardiology, University of Southern California, Los Angeles, CA; 3University of Southern California, Los Angeles, CA; 4Cardiothoracic Surgery, University of Southern California, Los Angeles, CA. Purpose: Extracorporeal membrane oxygenation (ECMO) is a technique to provide cardiac or respiratory support to patients with an otherwise fatal prognosis, ECMO continues to be associated with significant morbidity and mortality thus it is important to carefully evaluate for candidates. Methods: We retrospectively reviewed the charts of 135 patients at our institution who received veno-arterial (VA) or veno-venous (VV) ECMO between the years of 2012 to 2016 to identify predictors of outcome. Results: The mean age of VA ECMO patients was 58 years +/- 14, of which 63 were male. The most common indication for VA ECMO was postcardiotomy shock (45%) followed by cardiac arrest (17%), acute myocardial

Abstracts S331 infarction (14%), chronic heart failure (13%), acute respiratory failure (4%), acute cardiomyopathy (3%) and acute pulmonary embolism (3%). Twentyfour patients received ECMO at an outside hospital and were transferred to our center within 2 days. VA ECMO was de-cannulated in 51 patients, of which 30 survived to discharge (58% of those decannulated, 30% of total). Two patients received left ventricular assist devices and 7 received heart transplants. The most significant factor associated with survival to discharge in VA ECMO patients is the number of hospital days. Patients who were hospitalized for less than 14 days had a 95% mortality rate compared with a 40% mortality rate in those hospitalized more than 30 days. Higher BMI and platelets on admission were associated with increased survival to discharge while higher albumin and BUN and transfer from outside hospital on ECMO were associated with decreased survival to discharge. Based on advanced analyses, we created an equation to predict survival to discharge: .33+(Hospital days*.13)*(BMI*.003)*(BUN*-.005)*(Alb*-.014)*(Plt*.0003). Conclusion: Our study shows an approximate 30% survival rate in patients requiring VA ECMO, which is consistent with other studies, and in those who were decannulated, the rate improved to 58%. Survival rates on ECMO have not improved significantly over the years and it is extremely important to identify those who would truly benefit from such an advanced and invasive therapy. Our study identifies predictors of better outcomes and shows that those who receive VA ECMO and survive until decannulation have a higher chance of regaining cardiac function and survival or receiving a transplant/ mechanical circulatory device.

Purpose: Increasingly Extracorporeal Membrane Oxygenation (ECMO) is being used as a bridge to decision for recovery, transplantation or to a durable left ventricular assist device (LVAD) for patients presenting with cardiogenic shock. We report our outcomes in INTERMACS I patients receiving a durable LVAD after bridging with ECMO. Methods: A retrospective review of 20 consecutive INTERMACS profile I patients who were bridged from ECMO support to continuous-flow LVAD between May 2009 and September 2016 in Singapore was performed in order to evaluate our outcomes based on our management protocol. Results: 16 were males. The aetiologies include acute coronary syndrome in 12 (60%), dilated cardiomyopathy in 4 (23%), myocarditis in 3 (15%) and ischemic cardiomyopathy in 1 (5%). Mean age at the time of LVAD implant was 40 (± 14) years old. The total length of LVAD support was 33 patient months. Twelve patients received HeartMate II LVAD and two received HeartMate III LVAD. Six received HeartWare LVAD. Majority (18, 90%) were BTT while two were DT (10%). Median duration of ECMO support was 10 days (range 1-23). Mean length of hospital stay following LVAD implant was 50 days (range 15-99). There was is no in-hospital mortality. Kaplan Meier survival at 1-year was 100% and 91.7% at 3-years. Following LVAD implantation, four (20%) received cardiac transplant and one (5%) had LVAD explant following myocardial recovery. Conclusion: Our zero peri-operative mortality in this high risk group suggests that our management protocol is valid. The 3-years survival too appears to be favourable compared to INTERMACS registry data.

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Assessment of Lean Dorsal Muscle Surface Area by CT Scan and Effect on Outcomes in Heart Transplant Recipients: Results from a Single Center S. Joseph , G. Gonzalez-Stawinski, J. Hasse, G. Saracino, M. Edens, J. Felius, A. Jamil, S.A. Hall, B. Lima.  Baylor University Medical Center, Dallas, TX.

Outcomes of Patients Who Require Temporary Mechanical Circulatory Support Prior to Left Ventricular Assist Device Placement F. Mazzulla ,1 R. Cogswell,2 J. Schultz,1 A. Walts,2 J. Misialek,2 T. Thenappan,2 M. Pritzker,2 E. Missov,2 C.M. Martin,2 K. Liao,3 R. John.3  1Department of Medicine, University of Minnesota, Minneapolis, MN; 2Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, MN; 3Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of Minnesota, Minneapolis, MN.

Purpose: Frailty is defined as status of decreased physiological reserve which leads to a higher vulnerability to stressors and is associated with a higher risk of morbidity and mortality. Loss of muscle mass or sarcopenia has been linked with outcomes in critically ill and other surgical patients, but has not been assessed in heart transplant recipients. We aimed to assess the impact of sarcopenia by measuring dorsal muscle surface area in patients who received heart transplantation at our center. Methods: This was a retrospective single center study in a large volume heart transplant center. Lean dorsal muscle mass was measured using Sliceomatic CT scan software. Patients were divided into 3 groups by gender and muscle mass. Endpoints of interest analyzed included ICU length of stay, hospital length of stay, bleeding, 30 day mortality, and 1 year mortality. Results: Between the dates November 2012 and March 2016,179 patients were identified who had usable chest CT images and who underwent heart transplantation. Of these, 126 (70.4%) were male and 117 (65.4%) were White. From a nutrition standpoint, the subjective global assessment (SGA) risk was strongly associated with dorsal muscle mass (p= 0.0166). Compared to patients with high muscle mass, patients with low muscle mass had lower BMI (p< 0.001), fewer days on the waitlist (p= 0.007), fewer undersized donor by weight (p= 0.04) and by predicted heart mass (p= 0.03). Because we previously demonstrated that undersizing donors for mass increases mortality, we conducted the analysis excluding all patients in the entire study population who received a donor undersized by > 30% and found that sarcopenia was associated with increased ICU time and length of stay in men (p= 0.05) but not women. Conclusion: Assessing the impact of frailty and sarcopenia on post cardiac transplant outcomes is complex with multiple variables to consider. Lean dorsal muscle area may play a role after adjusting for other variables, but it appears to do so less so than in other disease states. 1( 016) Successful Bridge to Continuous-Flow Left Ventricular Assist Device Using Extracorporeal Membrane Oxygenation Support for INTERMACS Profile I Patients K.L. Kerk ,1 T.E. Tan,1 D. Sim,2 C.P. Lim,2 J.H. Tay,1 C.L. Neo,1 J.L. Tan,1 C. Sivathasan.1  1Cardiothoracic Surgery, National Heart Centre, Singapore, Singapore; 2Cardiology, National Heart Centre, Singapore, Singapore.

Purpose: There are limited published data on the outcomes of patients who require temporary mechanical circulatory support (MCS) prior to continuous flow left ventricular assist device (CF-LVAD) placement. The purpose of this analysis was to assess the outcomes of these patients in a contemporary CF-LVAD dataset. Methods: A retrospective review of 353 patients who received first time CF-LVAD support between the years of 2005 through 2016 was performed. Patients who required temporary MCS (extra extracorporeal membrane oxygenation (ECMO), biventricular support devices (Bi-VADs), or Impella) at the time of LVAD implantation as well as patients who were designated INTERMACS profile 1 were included in the analysis. Survival estimates were calculated using the Kaplan-Meier method. Results: A total of 40 patients underwent LVAD placement for refractory cardiogenic shock (INTERMACS profile 1). Of these, 11 (28%) were on temporary MCS at the time of LVAD implantation (2 biventricular support devices, 7 ECMO, 2 Impellas). Among these, 45% (5/11) required cardiopulmonary resuscitation during the hospitalization prior to LVAD placement. For the entire INTERMACS profile 1 cohort, the 30-day survival was 93% and 1-year survival was 77%. For those patients who required MCS prior to LVAD, the 30-day survival was 90% and the 1-year survival was 60%. Among the 11 patients who required temporary MCS, 5 remain listed for transplant, 4 died, 1 was explanted for myocardial recovery, and 1 has undergone successful cardiac transplantation. Being designated as bridge to transplant was associated with reduced mortality in the INTERMACS profile 1 patients (HR 0.34, 95% CI 0.14-0.97, p <  0.05). Conclusion: Patients who require mechanical circulatory support prior to LVAD placement have a relatively low 1-year survival, even in the modern era of CF-LVADs. Further work will be needed to determine which patients have a higher likelihood of survival in the presence of refractory cardiogenic shock. 1( 018) Predictors of Mortality in Cardiogenic Shock Patients Treated with Extra-Corporeal Cardiopulmonary Resuscitation S.J. Stein ,1 H. Takayama,2 A.R. Garan,3 V.K. Topkara,3 M. Salna,1 J. Han,1 P.A. Kurlansky,4 M. Yuzefpolskaya,3 M.A. Farr,3 P.C. Colombo,3