University Hospital, Salt Lake City, UT. Purpose: For patients with refractory cardiogenic shock, acute mechanical circulatory support (aMCS) can be a lifesaving ...
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The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
further changes in workload. Randomization determined the sequence of the two submaximal tests. Patient and physician were blinded to the sequence. Exercise duration, oxygen consumption (VO2) and rate of perceived exertion (RPE) on Borg Scale (6-20) were recorded. Results: Nineteen patients (all HeartMate II) completed 57 exercise tests. Baseline pump speed was 9,326 ± 378 rpm and support duration 1017 ± 828 days. Peak VO2 was 12.6 ± 4.3 ml/min/kg, 89% was NYHA I-II. At AT workload was 63 ± 26 W (25-115W) and VO2 79 ± 14% of max. Exercise duration improved by 106 ± 217 s (~16 ± 28%) in TestSub+ compared with TestSub(837 ± 358 vs 942 ± 359 s; p= 0.048). Neither baseline VO2 (p= 0.35) nor sequence of submaximal exercise tests (p= 0.19) were related to difference in exercise time. After exercising one minute with maximal load, RPE tended to be lower with increased pump speed; TestSub- 14 ± 2.5 vs TestSub+13.2 ± 2.6 (p= 0.056). Conclusion: Increasing pump speed by 800 rpm during sustained low intensity physical activity is safe and prolongs exercise duration in CF-LVAD patients. Furthermore perception of exertion tended to improve with increased pump speed but this potential effect requires confirmation in larger studies. Automated pump speed increase during activity might attribute to improved quality of life by facilitating ADLs. 1( 097) Coagulation and Inflammation Profiles with Axial and Centrifugal Flow LVADs V. Tarzia , G. Bortolussi, J. Bejko, M. Gallo, M. Comisso, M. Carrozzini, M. Nadali, R. Bianco, T. Bottio, G. Gerosa. Cardiac Surgery, University of Padova, Padova, Italy. Purpose: Thromboembolic events significantly burden left ventricular assist device (LVAD) therapy. They are generally caused by an activation of the coagulation system, resulting from the contact with VAD’s artificial surface. Moreover, inflammatory response has also been related to the occurrence of adverse events. In this contest, in order to avoid hemorrhagic complications, the preventive antithrombotic treatment should be calibrated not only on the individual patient, but also considering the features of different devices. In the present study, we investigated the profiles of coagulation -in particular platelet activation- and signs of inflammation in patients with two different continuous-flow LVADs: Jarvik 2000, an axial flow pump, versus HeartWare HVAD, a magnetically levitating centrifugal pump. Methods: A total of 85 patients received an implantable LVAD (45 Jarvik and 40 HVAD) at our Institution between December 2008 and June 2015. We analyzed classical laboratory, thromboelastometric (ROTEM®) and aggregometric (MultiPlate®) tests before operation and at set follow-up intervals. Furthermore, starting February 2013, we evaluated markers of inflammation in 54 of these patients (27 Jarvik and 27 HVAD). Results: HeartWare patients had significantly higher platelet count, D-dimer, Intem MCF, Extem MCF and AUC at COL test. Conversely, in patients with Jarvik lactate dehydrogenase was notably increased. No significant differences were evidenced between the two pumps regarding markers of inflammation. However, both devices were associated with persistently elevated levels of CRP and IL-6, when compared to the normal reference values. Conclusion: Both devices seem to activate the inflammation system, a phenomenon deserving further investigation. On the other hand, a different effect on hemostasis was observed between the two pumps: HeartWare causes a marked activation of the coagulation system, while Jarvik is associated with signs of hemolysis. Therefore, we routinely treat HeartWare patients with both anticoagulant and antiplatelet therapy, while Jarvik patients are usually only anticoagulated. 1( 098) Advanced Heart Failure Therapies in a High Risk Urban Population B.A. Smith ,1 N. Uriel,1 S. Adatya,1 G. Sayer,1 N. Sarswat,1 S. Kalantari Tannenbaum,1 J. Grinstein,1 K. Marinescu,1 V. Kagan,2 C. Juricek,2 H. Ruedlinger,2 V. Jeevanandam,2 T. Ota,2 G. Kim.1 1Division of Cardiology, University of Chicago, Chicago, IL; 2Cardiothoracic Surgery, University of Chicago, Chicago, IL. Purpose: New York Heart Association (NYHA) class III and IV heart failure patients typically follow a progressive deteriorating clinical course. Lack of timely referral for advanced heart failure therapies often results in signifi-
cant morbidity and mortality, especially in high risk patients. Our aim is to observe referral trends for advanced heart failure therapies in a high risk urban population. Methods: We followed a cohort of 98 patients who had their index heart failure hospitalization at an academic medical center after 2008 and continued to follow up at an urban outpatient clinic until 2012. Patients had Medicare or Medicaid insurance or were uninsured. The clinic was staffed by an advanced heart failure cardiologist and nurse practitioner, and it had direct referral capabilities to a local advanced heart failure center. We then performed a retrospective cohort analysis of heart failure outcomes in this population. Results: Analysis of demographic data and comorbidities indicates an overall high risk population. The average Charlson Index of comorbidities score was 4.47 +/- 2.9(SD), which corresponds to a 1-year survival of 73% and a 10-year survival of 38%. 96.1% of our patients were black with an average age of 48 +/- 14.2 (SD). The average ejection fraction (EF) was 32% +/15.3% (SD) and patients with an EF of less than 40%, had an average EF of 25% +/- 9.4 (SD). After the follow up period, 13% of our total cohort had died and 11.2% of our patients were offered advanced heart failure therapies; including 6 left ventricular assist devices, 3 heart transplantations, and 2 patients were on palliative inotropes. In addition, 60% of our patients had an improvement in ejection fraction over a time period of 3 months to 4 years. Though 53% of our patients did not have a follow up visit within 30 days of discharge, our cohort had a 30-day readmission rate of 15%. Conclusion: We describe a high risk population of patients at an urban outpatient heart failure clinic. Despite the lack of multidisciplinary and ancillary support in this clinic, many of these high risk patients received appropriate advanced heart failure therapies. This may indicate that high risk heart failure patients have better outcomes when they establish care at an outpatient clinic affiliated with an advanced heart failure center. 1( 099) Clinical Experience with Long-Distance Transportation of Patients on Acute Mechanical Circulatory Support Devices T. Kang ,1 B. Ko,2 S.G. Drakos,2 J. Stehlik,2 E.M. Gilbert,2 J. Nativi-Nicolau,2 O. Wever-Pinzon,2 J.C. Fang,2 A. Koliopoulou,1 S.I. Bott,3 J.E. Tonna,4 C.H. Selzman,1 S.H. McKellar.1 1Cardiothoracic Surgery, Utah University Hospital, Salt Lake City, UT; 2Cardiovascular Medicine, Utah University Hospital, Salt Lake City, UT; 3Anesthesiology, Utah University Hospital, Salt Lake City, UT; 4Emergency Medicine, Utah University Hospital, Salt Lake City, UT. Purpose: For patients with refractory cardiogenic shock, acute mechanical circulatory support (aMCS) can be a lifesaving procedure. Early access to aMCS and management in experienced centers is critically important. As device safety and technology improve, so will the ability to extend aMCS to patients at remote sites. The Intermountain West is unique due to the large geographical area, making transport of critically ill patients a challenge. We aim to define clinical outcomes and processes for long-distance transfer of patients on aMCS devices. Methods: We reviewed our experience of transporting patients long distances to our center who had already been placed on aMCS (Impella, Abiomed, Danvers, MA, USA) and extracorporeal membrane oxygenator (ECMO) devices. Outcomes were compared to international benchmark survival to hospital discharge data contemporaneously published by the Extracorporeal Life Support Organization (ELSO). Results: A total of 10 patients (80% men; mean age 53.5 ± 14.6 years) were transported without an accompanying physician to our center having been placed on aMCS at the transferring center. The etiology of cardiogenic shock was decompensated ischemic cardiomyopathy (n= 2), decompensated non-ischemic cardiomyopathy (n= 3), acute myocarditis (n= 2) and post-cardiotomy shock (n= 3). Average transport distance was 251 ± 165 miles (402 ± 264 km). Eight patients were transported by air, 2 by ground. aMCS device type was Impella CP (n= 5), ECMO (n= 3), and Impella 2.5 (n= 2). All patients were safely transported with no adverse events in-transit. Of the Impella patients, 4 required upgrade to ECMO for inadequate hemodynamic support upon arrival to our center. The average duration of aMCS was 9.5 ± 9.2 days. We observed ischemic stroke (n= 2) and access site complications (n= 3) consisting of lower leg ischemia and bleeding. 5 patients survived to explantation of aMCS devices and 4 survived to hospital discharge.
