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The use of extracorporeal life support (ECLS) has increased worldwide over the past years due to improved technology, ease of management, growing familiarity with its capability and decreased costs. We analysed use and outcomes of ECLS at our Centre. A retrospective cohort study of adults treated with ECLS for cardiogenic shock between January 2015 and April 2021 in a large London teaching hospital. We investigated patient characteristics, indications, and management to determine factors affecting outcomes. 95 patients underwent VA-ECLS of whom 46 were post-cardiotomy (PC) VA-ECLS patients. The mean age of the total cohort of patients was 52.3 years (range, 17-79 years), and 66.3% were male. Indications for ECLS included post-cardiotomy (PC) in 46/95 (48.4%), (post MI in 15/95 (15.8%), myocarditis in 13/95 (13.7%), and other in 21/95 (22.1%). The median duration of ECLS support was 5 days (range (0 - 30 days), and 37/95 (38.9%) of patients survived to discharge. Pre-ECLS procedures in PC patients in cardiogenic shock were isolated CABG in 4/46 (8.70%), isolated valve surgery in 20/46 (43.5%), thoracic aorta surgery in 13/46 (28.3%), CABG + valve in 6/46 (13.0%) or other surgery in 3/46 (6.52%). 16/46 (34.8%) were redo procedures; 24/46 (52.2%) were elective, 11/46 (23.9%) were urgent and 11/46 (23.9%) were emergency procedures. The mean age of this subset was 55.5 years (range 19 -79 years), 28/46 (60.9%) were males and 6/46 (8.7%) had pre-existing CKD. The mean EUROSCORE-II was 16.75. The median duration of ECLS support was 5 days (range 0-24 days) and 11/46 (23.9%) survived to discharge. Survival in PC patients (23.9%)) was significantly worse than in non-cardiotomy patients (26/49 (53.1%); p=0.0036). Our experience confirms satisfactory survival rates may be achieved in such a challenging ECLS setting. PC patients had lower survival rates. Strategies to improve the selection and outcomes of PC-ECLS patients are needed. Nevertheless, PC-ECLS remains a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. [ABSTRACT FROM AUTHOR]

Right ventricular failure (RVF) occurs in up to 35 % of patients who undergo left ventricular assist devices (LVAD) implantation. Our aim is to assess the relationship of inflow cannula (IFC) and outflow cannula (OFC) position with RVF outcome in centrifugal flow LVAD. Inflow cannula is a complex structure best assessed in a three-dimensional x-y-z plane. In this single-center retrospective study, we identified patients with centrifugal flow pumps implanted with optimal cardiac CT imaging and performed a novel point-based 3D measurement of IFC angle relative to the mitral valve as well as OFC angle and inflow depth. Baseline demographic data, pre and post-implant hemodynamics, Euromacs score and outcome data were collected for all patients. The main outcome was RVF as defined by mechanical circulatory support academic research consortium (MCS-ARC). Overall, 43 patients with 3D measurements were included where 27 subjects had HM III and 16 were on HVAD support. The median age was 64 (IQR [51-71]) with 67% patients being male. The IFC angle was higher in the RVF group versus the no RVF group 27 [19-31]vs 23 [15-29] but the result was not statistically significant (p=0.42). Hemodynamic analysis showed that right atrial pressure (RAP) was the most important predictor of RVF post LVAD. The relative change in RAP from in the RVF group was 3.2 mm Hg [1.11-5.35] higher than the no RVF group. The median Euromacs score of patients with early acute RVF was likely to be higher than those without RVF 7.3 [7.0, 7.5] vs 4.0 [2.0, 4.0]. However, the difference was not significant (p=0.13). In our small cohort, RAP remains the most significant predictor of RVF post-LVAD. Although, IFC was not statistically significant, but there was a signal towards more angulated IFC relative to mitral valve in patients with RVF. Further studies with larger sample size may elucidate the role of an optimal cannula position in mitigating the risk of RVF. [ABSTRACT FROM AUTHOR]

Patients with heart failure (HF) and sarcopenia and/or cachexia have a high mortality. No biomarkers are proven to diagnose or screen for sarcopenia in patients with HF. The purpose of this analysis is to assess the correlation between the sarcopenia index (SI) and CT quantified muscle measurements in advanced HF patients. We prospectively collected serum creatinine, cystatin C and pre-operative chest CT scans in 60 patients as part of routine LVAD evaluation between 5/19 to 3/21. The sarcopenia index was calculated using the following equation: (serum creatinine value/cystatin C value) × 100. To quantify muscle mass and quality, unilateral pectoralis muscle mass indexed to body surface area (PMI) and attenuation (approximated by mean Hounsfield units; PHUm) were measured on pre-operative chest CTs. The correlation between the SI and muscle measures was evaluated with linear regression. Seventy three percent were men (44/60) and 67 % (40/60) were designated as destination therapy. There was a significant correlation between the SI and both pectoralis muscle measures (Figure). Each 10 unit increase in SI was associated with a 0.43 cm2/m2 increase in PMI (95 % CI 0.11-0.76 increase, p =0.009) and a 3.47 HU increase in PHUm (95 % CI 2.08-4.87, p< 0.0001). This is the first study to demonstrate a correlation between the SI and CT derived muscle measurements in an advanced HF population. A HF sarcopenia biomarker has multiple potential clinical applications, including facilitating nutritional/rehabilitation interventions before wasting is clinically evident, as well as triggering earlier referral for advanced HF therapies. [ABSTRACT FROM AUTHOR]

Heart Transplant recipients previously exposed to CMV infection are considered intermediate risk for post-transplant CMV complications. Many centers therefore utilize "universal" prophylaxis for 3-6 months to mitigate this risk. However, it remains unclear how long prophylaxis should be continued post-transplant in this population. In the present analysis, we compared post-transplant CMV outcomes in patients receiving 3 vs. 6 months of valganciclovir prophylaxis in a multicenter, retrospective analysis. Retrospective analysis of 321 intermediate risk (CMV R+) HTx recipients from 6 U.S. centers between 2010-2018 treated with universal prophylaxis with valganciclovir for either 3 months (n = 277) or 6 months (n = 44). The primary endpoint was the development of CMV viremia or end-organ disease resulting in the escalation of anti-CMV therapy. The secondary endpoint was hospitalization for CMV-related infection. Of the 321 patients in the analysis, 13.4% (n = 43) developed CMV viremia or end-organ infection requiring escalation of anti-CMV therapy, and 3.4% (n = 11) were hospitalized for CMV infection. Overall, there was no significant difference in the primary endpoint in patients treated with 3 months of valganciclovir compared to 6 months (12.6% vs. 18.2%, p = 0.316; Figure 1A). There was a trend toward reduction in CMV hospitalization in the 6-month treatment group (Figure 1B), but this did not achieve statistical significance (3.6% vs. 2.3%, p = 0.651), potentially due to a low number of events. We found no difference in the risk of CMV viremia or hospitalization for CMV using either a 3-month or 6-month regimen for prophylaxis in HTx recipients at intermediate risk for CMV (R+). [ABSTRACT FROM AUTHOR]

Pectoralis muscle mass and tissue attenuation obtained on preoperative CT scans are powerful predictors of mortality after LVAD implantation. Gastrointestinal (GI) bleeding remains a common problem on mechanical support. It is unknown whether these skeletal muscle measures, which correlate with frailty and tissue quality, are associated with the development of recurrent GI bleeding. We performed a retrospective, multi-centered study which included patients with chest CTs performed ≤ 3 months prior to LVAD implantation at the University of Minnesota (n=143) and Houston Methodist Hospital (n=133). Unilateral pectoralis muscle mass indexed to body surface area (PMI) and attenuation (approximated by mean Hounsfield units; PHU m) were measured on preoperative chest CT scans. GIB events were captured for the first two years of LVAD support. Negative binomial regression analyses were performed to determine the association between pectoralis muscle measures and number of GIB events on LVAD support. The mean age of the study cohort was 59 + /- 13 years, 43 % were bridge to transplant and 62 % had ischemic cardiomyopathy. Thirty-two patients had at last one GI bleed while on LVAD support over 2 years. Both pectoralis muscle mass and tissue attenuation were associated with the incidence rate of GI bleeding on LVAD support. Each 5 unit increase in PHU m was associated with reduction in the incidence rate of GIB (adjusted 18 % reduction, 95 % CI 6-28 %, p = 0.005). Each unit increase in PMI was associated with a reduction in the incidence of GIB (adjusted 19 % reduction, 95 % CI 3- 34 %, p = 0.029). The final models were adjusted for age, sex, INTERMACS profile, BTT status, creatinine and albumin. Preoperative pectoralis muscle size and attenuation were associated with the development of recurrent GI bleeding after LVAD implantation in this multicenter cohort. This one time, internal assessment of patient substrate appears to predict not only mortality after LVAD, but morbidity as well. [ABSTRACT FROM AUTHOR]

Heart transplant recipients with prior exposure to cytomegalovirus (CMV R+) are considered intermediate risk for CMV-related complications. Current guidelines allow for a pre-emptive approach to CMV prophylaxis (i.e. "watch and wait" strategy) in these patients; however, it remains unclear if this is a safe and effective strategy to mitigate the risks of CMV reactivation. In the present study, we assessed the utility of a pre-emptive approach to CMV prophylaxis compared to a universal prophylaxis strategy in an intermediate risk population. Multi-center, retrospective analysis of 564 intermediate risk (CMV R+) HTx recipients from 6 U.S. centers between 2010-2018 with 18 months of follow-up. The primary endpoint was the development of CMV viremia or end-organ disease resulting in the initiation/escalation of anti-CMV therapy. The secondary endpoint was hospitalization for CMV-related infection. Of 564 intermediate risk (CMV R+) patients in the analysis, 123 (21.8%) were treated with a pre-emptive CMV prophylaxis strategy. Patient's treated with a pre-emptive approach had a significantly higher risk of both the primary (p < 0.001, Figure 1a) and secondary endpoints (p = 0.003, Figure 1b). Multivariable Cox regression analysis revealed a significant association between a pre-emptive strategy and the risk of the primary (HR 2.44, 95% CI 1.51 - 3.94, p < 0.001) and secondary (HR 2.66, 95% CI 1.13 - 6.28, p = 0.025) endpoints. The use of a pre-emptive prophylaxis approach in intermediate risk CMV HTx recipients (CMV R+) is associated with a significantly higher risk of both the need for therapy escalation and hospitalization for CMV-related complications. [ABSTRACT FROM AUTHOR]

Purpose Limited data exists regarding concentrated factor administration during continuous flow left ventricular assist device (CF-LVAD) implantation and subsequent rates of pump thrombosis. While the hemocompatability profile of CF pumps are presently changing, this is the largest concentrated factor experience reported in CF-LVAD patients to date. Methods Patients with first time HeartMate II implantation (n=328) were identified from a single center continuous-flow (CF-LVAD) database (n=400). Patients were coded as receiving concentrated factor if prothrombin 4 factor complex or recombinant factor VIIa was charted intra-operatively or within 48 hours of device implantation. Laboratory and hospitalization data were reviewed to determine time to first suspected or confirmed pump thrombosis. Suspected pump thrombosis was defined as a sustained rise in lactate dehydrogenase (LDH) > 2.5 the upper limit of normal. Confirmed pump thrombosis was defined as a pump exchange, cardiac transplant, or death associated with a hemolysis event. Multivariable cox regression was utilized to determine the association between concentrated factor administration and the time to suspected or confirmed pump thrombosis. Results Eighteen percent of patients (59/328) received concentrated factor intra-operatively or within 48 hours of device implantation. On multivariate analysis, concentrated factor administration was not significantly associated with time to first suspected pump thrombosis (HR 1.17, 95 % CI 0.62-2.20, p = 0.62) or confirmed pump thrombosis (HR 1.19, 95 % CI 0.43-3.3, p = 0.73). All models were adjusted for discharge pump speed, age, bridge to transplant status, diabetes, and INTERMACS profile. Conclusion While no statistical association was observed between concentrated factor administration and subsequent pump thrombosis in this large single center analysis, further data will be needed to answer this question in the contemporary continuous flow era. [ABSTRACT FROM AUTHOR]

We previously developed a post LVAD mortality prediction model using multicenter data incorporating pectoralis muscle mass and tissue attenuation obtained on preoperative CT scans. The purpose of this analysis was to evaluate the performance of this model in a prospective cohort including the most contemporary LVADs. Since 2016, all patients who underwent first time LVAD implantation at the University of Minnesota had chest CTs performed prior to surgery (n=82). None of the patients included in the Minnesota Pectoralis Muscle Risk Score (MPRS) development cohort were included in this analysis. Unilateral pectoralis muscle mass indexed to body surface area (PMI) and attenuation (approximated by mean Hounsfield units; PHU m) were measured from pre-operative CT scans. MPRSs were calculated on all patients using the following variables: PHU m , PMI, African American race, creatinine, total bilirubin, body mass index, bridge to transplant status and presence or absence of contrast. Cox regression analysis was performed to test the association between the MPRS and post LVAD mortality. Receiver-operating characteristic (ROC) curves were then generated to test model discrimination at 30 and 90 days post LVAD implantation. The prospective cohort included 62% HeartMate 3, 17% HVAD, and 20% HeartMate 2 devices. Each two point increase in MPRS was associated with a 2.6 fold increase in the mortality after LVAD (HR 2.6, 95% CI 1.3-5.4, p=0.01). The area under the curve for the MPRS was 0.73 at 30 days and 0.72 at 90 days. The Pectoralis Muscle Risk Score had favorable discrimination in this contemporary prospective cohort, which was largely comprised of patients receiving HeartMate 3 devices. These skeletal muscle measures, which are associated with heart failure stage and frailty, continue to add important information to pre-operative risk assessment. [ABSTRACT FROM AUTHOR]

Although inflammatory features have been reported in the pressure-overloaded right ventricle, prior proteomic studies of pulmonary arterial hypertension (PAH) have mainly focused on identifying circulating biomarkers associated with pulmonary vascular disease severity or outcomes. This study sought to determine the circulating proteomic immune profile associated with right heart maladaptive phenotype (RHMP) in PAH. In this observational study of PAH patients enrolled at Stanford University from 2008-2011 (n=121, discovery cohort) and from 2011-2014 (n=76, validation cohort), we carried out plasma proteomic profiling using Luminex® multiplex immunoassay (48-plex of interleukins, chemokines and growth factors). RHMP was defined by the Mayo right heart score (based on echocardiographic right ventricular RV strain, NYHA class and NT-proBNP) and Stanford right heart score (based on RV end-systolic remodeling index, NYHA class and NT-proBNP). The association between cytokines and RHMP was assessed by partial least square regression (PLS-R). To further validate the circulating markers associated with RHMP, we confirmed tissue-level expression in RV biopsies from PAH patients. Median age was 50 [39-59] years in the discovery cohort, where the majority of patients was female (74%) and PAH was most commonly associated with connective tissue disease (33%). Patients from the validation cohort had more severe features (lower six minute walk test distance, lower cardiac index and higher levels of NT-proBNP) than patients from the discovery cohort, with similar resistance levels and right heart echocardiography metrics. High levels of hepatic growth factor (HGF), stem cell growth factor beta (SCGFβ), nerve growth factor (NGF) and SDF1 were significantly associated with worst Mayo and Stanford scores but not with pulmonary vascular resistance or mean pulmonary arterial pressure, in both cohorts. In the right ventricle of deceased PAH patients, we confirmed expression of HGF and its receptor cMet using immunofluorescence. High plasma levels of HGF, SCGFβ, NGF and SDF1 are associated with RHMP in PAH, independent of pulmonary vascular disease severity. The HGF-cMet pathway warrants further exploration to investigate a potential RV specific therapeutic target. [ABSTRACT FROM AUTHOR]

Physical frailty is a predictor of pre- and early post-transplant outcomes in lung transplant patients, and may be driven by the presence of sarcopenia (loss of muscle mass), dynapenia (decline in muscle contractile function) and/or mobility limitations. The purpose of this study was to examine the association between physical frailty (Fried Frailty Index; FFI) and measures of sarcopenia, dynapenia and mobility in lung transplant candidates. As a secondary aim, we examined the relationships between sarcopenia and dynapenia. 49 lung transplant candidates from the Frailty and Sarcopenia in Organ Transplantation (FROST) cohort study were included. Frailty was evaluated using the FFI. Dynapenia was assessed by quadriceps muscle strength and power using computerized dynamometry. Sarcopenia was evaluated using B-mode ultrasound to obtain quadriceps (rectus femoris) cross-sectional area (CSA) and muscle quality (echogenicity). Mobility was measured using the Short Physical Performance Battery (SPPB). Bivariate associations were examined using Spearman's rho. The sample included 24 patients with ILD, 18 with COPD, and 7 with other diagnoses (53% females; age 59.6±13yrs, FEV 1 1.14±0.66L, BMI 25.3±4.0 kg/m2). Based on the FFI, 22% were frail, 71% were pre-frail, and 6% were not frail. There was an association between FFI and the SPPB score (r= -0.41, p=0.003); specifically, with the chair stands component of the SPPB (r=0.30, p=0.035). No significant correlations were found between FFI and sarcopenia or dynapenia measures. Quadriceps muscle strength and power were associated with muscle CSA (r=0.44 and 0.47, respectively; p< 0.002) and echogenicity (r= -0.38 and -0.58, respectively; p< 0.008). Mobility limitations appear to overlap with the frailty phenotype in lung transplant candidates, however the presence of sarcopenia and dynapenia may be distinct from frailty. [ABSTRACT FROM AUTHOR]

Employment status has been linked to worse outcomes in heart failure. Employment status at the time of LVAD evaluation has not been assessed as a predictor of post-LVAD patient outcomes. The study cohort consisted of patients who were implanted with continuous flow LVADs at the University of Minnesota between June 2005 and June 2018 who had complete psychosocial evaluation data available. Patients were classified as employed, retired, or unemployed. Cox and negative binomial regression models were used to measure the association between employment status and post LVAD mortality and number of 1 year all cause admission, respectively. The study cohort included 428 patients. Patient were almost equally distributed among the three groups with 157 (37%) unemployed, 135 retired (33%), and 136 employed (32%). Patients who were employed leading up to LVAD implantation had higher socioeconomic status, lower BMIs, and lower reported smoking history (table). Being employed (vs. retired/unemployed) at the time of LVAD evaluation was associated with lower HR for mortality (unadjusted HR 0.50, 95% CI 0.34 - 0.73, P<0.001 - adjusted HR 0.62, 95% CI 0.39 - 0.98, P=0.042). Employed status was also associated with a reduced incidence rate of 1 year readmission (adjusted 27 reduction in incidence rate ratio (IRR) 95% CI 8 % - 63 % reduction, P=0.010). When excluding the retired population, employed vs. unemployed status was not statistically associated with mortality (adjusted HR 0.71, 95 % CI 0.44- 1.11, p = 0.16) however was associated with reduced incidence rates of hospitalization on LVAD support (adjusted 31 % reduction, 95 % CI 11-47 % reduction). Patients who were employed at the time of LVAD evaluation had improved survival and lower rates of hospitalization on LVAD support even after adjustment for socioeconomic and clinical variables in this single center analysis. [ABSTRACT FROM AUTHOR]

The association between pectoralis muscle measurements and objective frailty assessments in the heart failure population has not been previously reported. The study cohort included patients who had first-time CF-LVAD implants at the University of Minnesota between 2017-2018 who had 1) chest CTs and 2) frailty assessments performed in the 3 months prior to LVAD (n=27). Unilateral pectoralis muscle mass indexed to height in meters squared and attenuation (approximated by mean Hounsfield units) were measured on preoperative chest CT scans ​using Slice-O-Matic software. Frailty was assessed with a 6 point Clinical Frailty Scale. Multivariable linear regression was performed to assess the association between pectoralis muscle measures and frailty scores. After multivariate adjustment, each frailty score increase (more frail) was associated with an adjusted decrease of 3.9 in the mean pectoralis muscle hounsfield units (95% CI= -7.4 to -0.41, p=0.03). A statistically significant association between pectoralis muscle mass index and frailty scores was not detected (-0.61 95% CI = -1.4 to 0.2; p =0.15). Multivariable models were adjusted for age, sex, and INTERMACS profile. In this small sample of patients with simultaneous frailty and pectoralis muscle measurements, a significant association was detected between tissue attenuation and frailty. Further data will be needed to confirm this finding and to determine the degree that frailty can be reversed with LVAD support. [ABSTRACT FROM AUTHOR]

Purpose The EUROMACS Right-Sided Heart Failure Risk Score was developed to predict right ventricular failure (RVF) after left ventricular assist device (LVAD) placement. The performance of this model outside the derivation cohort has not been tested. Methods EUROMACS Right-Sided Heart Failure Risk Scores were calculated and assessed as predictors of post-operative RVF in a single center continuous flow (CF) LVAD cohort (n=451). Only patients with complete data for risk score calculation and RVF determination were included in the analysis (n = 254). RVF was defined as RVAD within 30 days, continuous inotropic support ≥ 14 days, or inhaled pulmonary vasodilatory use for > 48 hours after LVAD implantation. Results Thirty-nine percent of patients (100/254) had post-operative RVF, however only 9% (23/254) required prolonged inotropic support and 5% (12/254) required RVAD placement. Development of RVF after LVAD was associated with a 45% increase the hazards rate of death on LVAD support (HR 1.45, 95 % CI 0.98-2.2, p =0.066), however this was not statistically significant. The increase in mortality associated with RVF was largely driven by patients who required RVAD support (HR 4.6, 95 % CI 2.3- 9.1, p <0.001). Two of the predictors included in the EUROMACS Right Sided Heart Failure Risk Score were not predictive of RVF in this dataset (hemoglobin, p=0.3, right atrial pressure to pulmonary capillary wedge pressure ratio, p=0.4). The area under the curve for EUROMACS Right-Sided Heart Failure Risk Score to predict RVF was 58% (95 % CI 52-66%). Conclusion The EUROMACS Right-Sided Heart Failure Risk Score had poor discrimination in this LVAD dataset. These findings further emphasize the difficulty of predicting RVF after LVAD placement. Further work is required to enhance our understanding pre- LVAD right ventricular physiology and to accurately risk stratify patients. [ABSTRACT FROM AUTHOR]

Purpose As skeletal muscle mass and quality decrease with heart failure progression, we hypothesized that pectoralis muscle mass and tissue attenuation measured on pre-left ventricular assist device (LVAD) CT scans would add meaningful heart failure severity stratification beyond INTERMACS profile alone. Methods Patients with chest CTs performed ≤ 3 months prior to LVAD implantation at University of Minnesota (n=143) and Houston Methodist Hospital (n=133) were identified from the larger cohorts (University of Minnesota n=353, Houston Methodist =278). Unilateral Pectoralis muscle mass indexed to body surface area and pectoralis muscle attenuation (approximated by mean Hounsfield units; PHU m) was measured on pre-operative chest CT scans. Patients within each INTERMACS profile were separated into HIGH and LOW pectoralis muscle measure groups (HIGH = upper two pectoralis muscle tertiles, LOW = lowest pectoralis muscle tertiles, repeated for both PMI and PHU m). Kaplan Meier survival analyses were performed to compare mortality among INTERMACS profiles by HIGH and LOW pectoralis muscle measure groups. Results INTERMACS 3 and 4 patients in the HIGH PHUm groups had the highest survival on LVAD support (2-year survival 80%, 95% CI 70 - 87%, p =0.0002). When the analysis was repeated for PMI, INTERMACS 3 and 4 patients in the HIGH PMI groups had the highest survival on LVAD support (2-year survival 80%, 95% CI 70 - 87%, p = 0.004). Conclusion INTERMACS 3 and 4 patients with the highest pectoralis muscle measures had the best survival on mechanical support. As skeletal muscle wasting is accelerated with advanced heart failure, these measures may help identify patients in whom watchful waiting is not safe. Further data will be required to confirm this hypothesis. [ABSTRACT FROM AUTHOR]

Purpose We have previously shown that pectoralis muscle mass and tissue attenuation obtained on preoperative CT scans were powerful predictors of mortality after LVAD implantation using single center data. This analysis confirms those findings in a separate LVAD dataset and presents a novel prediction model developed across centers. Methods Patients with chest CTs performed ≤ 3 months before LVAD implantation at University of Minnesota (n=143) and Houston Methodist Hospital (n=133) were identified from larger cohorts (University of Minnesota n=353, Houston Methodist =278). Unilateral pectoralis muscle mass indexed to body surface area (PMI) and attenuation (approximated by mean Hounsfield units; PHU m) were measured on preoperative chest CT scans. To develop the Pectoralis Muscle Risk Score (PMRS), we implemented a cross-validated model selection using Cox's proportional hazards regression model with censoring at transplantation. The final model included PHU m , sex, albumin, year of implant, body mass index, bridge to transplant, INTERMACS profile, and presence or absence of contrast. Receiver-operating characteristic (ROC) curves for 30, 90, and 365 day survival were generated for the model and compared to the HeartMate II Risk Score (HMRS). Results The Pectoralis Risk Score outperformed HMRS at each of the pre-specified time-points. The AUC for PMRS for predicting survival at 30, 90, and 365 days was 78%, 76%, and 76%, respectively. The HMRS had AUC of 63%, 67%, and 63% (Figure). Conclusion The Pectoralis Muscle Risk Score had favorable discrimination in this multicenter dataset. These skeletal muscle measures, which are associated with heart failure stage and frailty, appear to add important information to pre-operative risk assessment. [ABSTRACT FROM AUTHOR]

Purpose The role of routine right heart catheterization (RHC) to evaluate for left ventricular (LV) unloading remains unclear in patients with continuous flow left ventricular assist devices (CF-LVAD). We hypothesized that persistently elevated pulmonary capillary wedge pressure (PCWP) would be associated with increased mortality on CF-LVAD support. Methods A single center continuous flow LVAD cohort (n=451) was queried for patients with follow-up RHC data at 6 months +/- 3 months (n=179). To determine the relationship between follow-up PCWP and mortality, a multivariable cox regression analysis was performed. Results The mean age of the study cohort was 57±13 years. 79% (141/179) were males, 56% (101/179) had ischemic cardiomyopathy and 74% (133/179) were designated bridge to transplant (BTT). The median follow-up time on LVAD support after RHC was 4.4 years. The only pre-implant variables that were associated with elevated PCWP in the multivariate analysis were renal function and BMI (each 2.5 unit increase in BMI was associated with an adjusted 0.6 mmHg increase in follow-up PCWP, 95% CI 0.2-0.9 mmHg, p=0.004; each 0.5 mg/dL increase in creatinine was associated with a 1.2 mmHg increase in follow-up PCWP, 95% CI 0.4-2.1, p=0.003). In the final multivariate models, each 5 mmHg increase in PCWP at the time of RHC was associated with a 22% increase in the hazards rate of death during follow-up (adjusted HR 1.2, 95% CI 1.01-1.47, p=0.039). All models were adjusted for age, sex, INTERMACS profile, body mass index, bridge to transplant status and renal function. Conclusion Incomplete LV unloading following CF-LVAD implantation is associated with increased all-cause mortality. Our results emphasize the importance of invasive hemodynamic optimization in this patient population. Further studies are warranted to determine the optimal filling pressures in patients with CF-LVAD. [ABSTRACT FROM AUTHOR]

Purpose Limited data exists regarding concentrated factor administration during continuous flow left ventricular assist device (CF-LVAD) implantation and subsequent neurologic events. While the hemocompatability profile of CF pumps are presently changing, this is the largest concentrated factor experience reported in a CF-LVAD population to date. Methods The study cohort consisted of patients with a first time HeartMate II implantation at a single center (n=330). Patients were coded as receiving concentrated factor if prothrombin 4 factor complex or recombinant factor VIIa was charted intra-operatively or within 48 hours of device implantation. Time to first stroke (ischemic or hemorrhagic) was recorded using INTERMACS definitions. Multivariate cox regression was used to assess the association between concentrated factor administration and the time to first stroke. Results Eighteen percent of patients (60/330) received concentrated factor intra-operatively or within 48 hours of device implantation. During a median follow up time of 488 days, 47 patients developed a stroke on LVAD support (51% ischemic, 49% hemorrhagic). In the final multivariate models, concentrated factor administration was not significantly associated with all cause stroke (HR 0.70, 95% CI 0.32-1.72, p = 0.50), ischemic stroke (HR 1.23, 95% CI 0.43-3.56, p = 0.7), or hemorrhagic stroke (0.39, 95% CI 0.09-1.75, p =0.22). All models were adjusted for age, INTERMACS profile, implant year, ischemic cardiomyopathy diagnosis, diabetes, presence or absence of atrial fibrillation at implantation, and discharge pump speed. Conclusion While there was no statistical association with stroke rates after concentrated factor administration, the hazard ratios suggests a protective effect against hemorrhagic events and a slight increase in ischemic events with factor administration. Larger data will be needed to fully answer this question in the contemporary continuous flow era. [ABSTRACT FROM AUTHOR]

Purpose We have previously demonstrated that pectoralis muscle mass and tissue attenuation measured on preoperative CT scans were powerful predictors of mortality after LVAD implantation. These measurements were made with specialized software (Slice-O-Matic) which is not accessible to advanced heart failure teams. The purpose of this analysis was to determine the correlation between pectoralis muscle measures made with specialized software vs. routinely available CT software (PACS). Methods A random sample CT scans (n=57) was selected from our larger LVAD cohort with previously quantified pectoralis muscle measures by Slice-O-Matic Software (larger cohort n=141). Unilateral pectoralis muscle mass indexed to body surface area (PMI) and attenuation (approximated by mean Hounsfield units; PHU m) were re-measured on preoperative chest CT scans by a local radiologist using PACS software. Correlation between Slice-O-Matic and PACS pectoralis muscle measures was performed with Pearson analysis. These measures (PACS) were then assessed as predictors of mortality after LVAD implantation using multivariate cox regression. Results We observed a high correlation between pectoralis muscle measures using both techniques (R = 0.95 for PMI, R = 0.94 for PHU m). For the pectoralis measures quantified by PACS, each unit increase in PMI was associated with a 31% reduction in the hazard of death after LVAD (adjusted HR 0.69, 95% CI 0.48-0.99, p = 0.046). Each 5-unit increase in PHU m was associated with a 39% reduction in the hazard of death after LVAD (adjusted HR 0.61, 95% CI 0.38-0.96, p < 0.036). Models were adjusted for sex, albumin, log NT-proBNP, INTERMACS profile, right atrial pressure, and bridge to transplant status. Conclusion Pectoralis muscle measurements can be performed by local radiologists using routinely available software. These measures are predictive of morality following LVAD. This is an important first step in delivering a predictive model incorporating this measure into real world practice. [ABSTRACT FROM AUTHOR]

Purpose Right ventricular failure (RVF) after LVAD implantation remains difficult to predict pre-operatively. As right heart failure is associated with muscle wasting, we hypothesized pectoralis muscle tissue attenuation quantified on pre-operative CT scans would enhance the prediction of RVF after LVAD implantation. Methods Patients with a first time continuous flow (CF) LVAD implants from Houston Methodist (n=208) and University of Minnesota (n=224) with complete post-operative RVF data were included in the analysis (total n = 432). As we wanted to create a model that applied to INTERMACS 2-5 patients, we limited the analysis to INTERMACS 2 and higher patients. RVF was defined as RVAD within 30 days of implantation or requiring inotropic support ≥ 14 days. To develop an RVF Risk Model, we implemented backward model selection using logistic regression. Thirty-one candidate hemodynamic and clinical predictors were tested during model development. This method was repeated limiting the analysis to patients with mean pectoralis Hounsfield units (PHU m) available by pre-operative CT scans (total n=188). Receiver-operating characteristic (ROC) curves for the RVF Risk Model and the Pectoralis RVF Risk Model were then generated. Results The RVF Risk Model included the following variables: albumin, log total bilirubin, and INTERMACS profile. The AUC for this model was 69% (95% CI: 62-76%). The Pectoralis RV Risk Model included albumin, creatinine and PHU m. The AUC for this model was 73% (95 % CI: 63-82%). Conclusion Pectoralis muscle tissue attenuation was predictive of RVF after LVAD implantation in this multicenter study. Incorporating this measure into a RVF Risk Model improved model performance. This measure is quantifiable, repeatable, and appears to add information to traditional preoperative assessment. [ABSTRACT FROM AUTHOR]