Months Of Left Ventricular Assist Device Support Research Articles

Long-term outcomes after percutaneous withdrawal of HeartWare left ventricular assist device (HVAD) support: A 10-year update

Ten years have passed since we reported percutaneous decommissioning of an implantable left ventricular assist device (LVAD) using two Amplatzer vascular plugs in a 17 year-old male who was bridged to recovery after 22 months of LVAD support. Whilst his left ventricular (LV) dimensions never completely normalised and there has been persistent mild impairment of LV systolic function, the patient remains free of heart failure symptoms and his natriuretic peptide level has been well suppressed on guideline-directed medical therapy. He is anticoagulated with Warfarin. There have been no adverse events relating to either the decommissioned LVAD or the percutaneous driveline remnant, or anticoagulation. This case highlights the potential for long-term survival without adverse events in individuals who are left with a redundant implantable LVAD after successful percutaneous withdrawal of mechanical circulatory support.

Cardiac Cachexia in Left Ventricular Assist Device Recipients and the Implications of Weight Gain Early After Implantation.

Background Severe cardiac cachexia or malnutrition are commonly considered relative contraindications to left ventricular assist device (LVAD) implantation, but post-LVAD prognosis for patients with cachexia is uncertain. Methods and Results Intermacs (Interagency Registry for Mechanically Assisted Circulatory Support) 2006 to 2017 was queried for the preimplantation variable cachexia/malnutrition. Cox proportional hazards modeling examined the relationship between cachexia and LVAD outcomes. Of 20 332 primary LVAD recipients with available data, 516 (2.54%) were reported to have baseline cachexia and had higher risk baseline characteristics. Cachexia was associated with higher mortality during LVAD support (unadjusted hazard ratio [HR], 1.36 [95% CI, 1.18-1.56]; P<0.0001), persisting after adjustment for baseline characteristics (adjusted HR, 1.23 [95% CI, 1.0-1.42]; P=0.005). Mean weight change at 12 months was +3.9±9.4 kg. Across the cohort, weight gain ≥5% during the first 3 months of LVAD support was associated with lower mortality (unadjusted HR, 0.90 [95% CI, 0.84-0.98]; P=0.012; adjusted HR, 0.89 [95% CI, 0.82-0.97]; P=0.006). Conclusions The proportion of LVAD recipients recognized to have cachexia preimplantation was low at 2.5%. Recognized cachexia was independently associated with higher mortality during LVAD support. Early weight gain ≥5% was independently associated with lower mortality during subsequent LVAD support.

Left ventricular assist devices promote changes in the expression levels of platelet microRNAs.

MicroRNAs (miRs) emerged as promising diagnostic and therapeutic biomarkers in cardiovascular diseases. The potential clinical utility of platelet miRs in the setting of left ventricular assist device (LVAD) support is unexplored. We prospectively measured the expression levels of 12 platelet miRs involved in platelet activation, coagulation, and cardiovascular diseases in LVAD patients by quantitative real-time polymerase chain reaction. Data were longitudinally measured before LVAD implant and after 1, 6, and 12 months of LVAD support, and compared with those measured in healthy volunteers (controls). In silico analysis was also performed to identify pathways targeted by differentially expressed miRs. Data from 15 consecutive patients and 5 controls were analyzed. Pre-implant expression levels of platelet miR-126, miR-374b, miR-223, and miR-320a were significantly different in patients vs. controls. The expression levels of platelet miR-25, miR-144, miR-320, and miR-451a changed significantly over the course of LVAD support; in silico analysis revealed that these miRs are implicated in both cardiac- and coagulation-associated pathways. Furthermore, the patients who suffered from bleeding (n = 5, 33%) had significantly higher pre-implant expression levels of platelet miR-151a and miR-454 with respect to the patients who did not. The same miRs were also differentially expressed in bleeders following LVAD implantation early before the clinical manifestation of the events. This study provides a proof-of-concept evidence of significant modulation of platelet miRs expression driven by LVADs. The possible existence of a platelet miRs signature predictive of the development of bleeding events warrants further validation studies.

Skeletal Muscle Mass Recovery Early After Left Ventricular Assist Device Implantation in Patients With Advanced Systolic Heart Failure.

Patients with advanced systolic heart failure are at risk of unintentional weight loss and muscle wasting. It has been observed that left ventricular assist device (LVAD) recipients gain weight after device implantation, although it is unknown whether this represents skeletal muscle mass gains. We aimed to determine whether skeletal muscle mass increases early during LVAD support. We prospectively recruited 30 adults with systolic heart failure ±21 days from LVAD implantation. Participants underwent whole-body dual X-ray absorptiometry to measure fat free mass, appendicular lean mass (ALM, lean mass in the arms and legs) and fat mass. Dual X-ray absorptiometry imaging was repeated at 3 and 6 months after LVAD implantation, with participation ending after the 6-month visit or heart transplantation, whichever occurred first. Changes in body composition were evaluated using mixed effects linear regression models. The cohort was 87% male, with mean age 56±12 (SD) years, and mean body mass index 26.4±5.4 kg/m2. Per sarcopenia ALM criteria, 52% of participants had muscle wasting at baseline. At baseline, mean fat free mass and ALM were 56.4±11.7 and 21.0±5.3 kg, respectively. Both measures increased significantly (P<0.001) over 6 months of LVAD support: mean fat free mass change at 3 and 6 months: 2.3 kg (95% CI, 1.0-3.5) and 4.2 kg (95% CI, 2.2-6.1); mean ALM change at 3 and 6 months: 1.5 kg (95% CI, 0.7-2.3) and 2.3 kg (95% CI, 0.9-3.6). Among LVAD recipients with advanced systolic heart failure and high baseline prevalence of muscle wasting, there were significant gains in skeletal muscle mass, as represented by dual X-ray absorptiometry fat free mass and ALM, over the first 6 months of LVAD support.

Thyroid Function at Left Ventricular Assist Device (LVAD) Implantation Predicts Prognosis During LVAD Support

<h3>Purpose</h3> The purpose of this study was to assess thyroid status before and during left ventricular assist device (LVAD) support and to estimate an impact of thyroid status at LVAD implantation on survival. <h3>Methods</h3> We retrospectively analyzed thyroid function profile including thyroid- stimulating hormone (TSH), free triiodothyronine (fT₃), and free thyroxine (fT₄) in a group of all consecutive 147 patients (93.2%- male, BMI-26.7 ±5.6, mean and median INTERMACS profile- 3; 53% -ischemic etiology of heart failure) implanted with continuous-flow LVAD in our institution within years 2009-2021 (54%-HeartMate3; 40%- HeartWare; 6%- Heart Mate II). One year survival was 78.3%. Fifteen percent of patients received amiodarone, whereas 20.4%- supplementation of levothyroxine and 2% - thyreostatic treatment during LVAD support. Statistical methods used were: ROC curves, when Youden factor > 0.27- Chi 2 test, analysis of variance, Bonferroni test. <h3>Results</h3> Mean values of TSH, fT₃ and fT₄ were respectively 2.33 ± 1.69 uIU/ml; 2.14± 0.56 pg/ml; 1.25 ± 0.36 ng/dl before, 2.95 ± 3.18 uIU/ml; 2.47±1.35 pg/ml; 1.11 ±0.27 uIU/ml and 2.0 ±1.27 ng/dl; 2.43 ±0.42 pg/ml; 1.22 ± 0.25 ng/dl at 3 months and at 12 months post LVAD implantation. Mortality risk was 2.8 times lower for patients presenting TSH ≥ 1.29 uIU/ml (p= 0.01) and 3.8 times lower for patients presenting fT₃ ≥ 1.93 uIU/ml (p=0.003) at LVAD implantation. TSH significantly decreased between 3 and 12 months of LVAD support (Bonferroni test, p<0.009), whereas fT3 increased significantly after 3 and 12 months as compared to values before LVAD implantation (Bonferroni test, p < 0.039 and p<0.041 respectively). <h3>Conclusion</h3> Thyroid function may have an impact on survival in patients with end-stage heart failure implanted with LVAD. Thyroid status surveillance and its corrections could improve the overall prognosis in this group of patients. Further studies are needed to confirm this thesis.

Evaluation of aspirin platelet inhibition in left ventricular assist device population.

Aspirin therapy is recommended in durable left ventricular assist device (LVAD) patients to prevent thromboembolic complications. Up to 30% of patients treated with aspirin may demonstrate aspirin resistance, which has been related to thrombotic complications. However, it is unknown whether individual patients exhibit temporal alterations in aspirin sensitivity during LVAD support. We hypothesized that aspirin platelet inhibition would wane after the initial postimplant period. This was a retrospective, observational, single center study conducted at an academic medical center. This study evaluated changes in aspirin platelet inhibition over the first 6 months of LVAD support. Patients who underwent placement of centrifugal LVAD with aspirin platelet sensitivity assays were included for analysis. Aspirin responsiveness was assessed postimplant after 5 days, 3 months, and 6 months. A total of 28 patients were included for analysis of which 7% of patients were aspirin resistant initially. At 3 months, 32% (odds ratio [OR], 6.1, p = .03) of patients were aspirin resistant and 28% (OR, 4.1, p = .1) at 6 months. Over the first 3 months postimplant, the odds of aspirin resistance increased sixfold and remained relatively constant at 6 months. Patients who were aspirin resistant and received an increase in aspirin dose at 3 months subsequently had a sensitive ARU at 6 months. Aspirin responsiveness not only varies between patients but can significantly wane within individual LVAD patients over time. Additional study is needed to determine if monitoring aspirin resistance may prevent thrombotic complications after LVAD implantation.

Quality of Life Following Urgent LVAD Implantation for ECMO Therapy in Cardiogenic Shock: A Long-Term Follow-Up.

Background and Objectives: Over the past decade, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has developed into a mainstream treatment for refractory cardiogenic shock (CS) to maximal conservative management. Successful weaning of VA-ECMO may not be possible, and bridging with further mechanical circulatory support (MCS), such as urgent implantation of a left ventricular assist device (LVAD), may represent the only means to sustain the patient haemodynamically. In the recovery phase, many survivors are not suitably prepared physically or psychologically for the novel issues encountered during daily life with an LVAD. Materials and Methods: A retrospective analysis of our institutional database between 2012 and 2019 was performed to identify patients treated with VA-ECMO for CS who underwent urgent LVAD implantation whilst on MCS. Post-cardiotomy cases were excluded. QoL was assessed prospectively during a routine follow-up visit using the EuroQol-5 dimensions-5 level (EQ-5D-5L) and the Patient Health Questionnaire (PHQ-9) surveys. Results: Among 126 in-hospital survivors of VA-ECMO therapy due to cardiogenic shock without prior cardiac surgery, 31 (24.6%) urgent LVAD recipients were identified. In 11 (36.7%) cases, cardiopulmonary resuscitation (CPR) was performed (median 10, range 1–60 min) before initiation of VA-ECMO, and in 5 (16.7%) cases, MCS was established under CPR. Mean age at LVAD implantation was 51.7 (+/−14) years and surgery was performed after a mean 12.1 (+/−8) days of VA-ECMO support. During follow-up of 46.9 (+/−25.5) months, there were 10 deaths after 20.4 (+/−12.1) months of LVAD support. Analysis of QoL questionnaires returned a mean EQ-5D-5L score of 66% (+/−21) of societal valuation for Germany and a mean PHQ-9 score of 5.7 (+/−5) corresponding to mild depression severity. When compared with 49 elective LVAD recipients without prior VA-ECMO therapy, there was no significant difference in QoL results. Conclusions: Patients requiring urgent LVAD implantation under VA-ECMO support due to CS are associated with comparable quality of life without a significant difference from elective LVAD recipients. Close follow-up is required to oversee patient rehabilitation after successful initial treatment.

Patient-Reported Health Status in Relation to Change in Skeletal Muscle Mass and Function during Left Ventricular Assist Device Support

Purpose Patients with heart failure (HF) frequently experience loss of skeletal muscle mass and strength. It is unknown if loss of muscle mass and/or strength in patients with HF is associated with quality of life (QoL) reductions. Understanding the relationship between loss of muscle mass, strength and HF-specific patient reported health status is essential in defining the clinical importance of skeletal muscle wasting. Methods We retrospectively analyzed data collected prospectively between 5/2016-3/2020 from patients with advanced systolic HF requiring left ventricular assist device (LVAD) support. There were 3 visits: 0 (baseline), 3 and 6 months of LVAD support. Each visit included whole-body dual X-ray absorptiometry (DXA) to calculate appendicular lean mass (ALM), a hydraulic hand dynamometer for handgrip strength, and a Kansas City Cardiomyopathy Questionnaire (KCCQ). KCCQ is a HF-specfic measure of patient-reported health status, symptoms, physical/social functioning and QoL, with summary scores ranging 0-100 (higher indicates better health status) and domain-specific subscores. Linear mixed effects models were used to evaluate relationships between ALM, handgrip strength and KCCQ scores over time, adjusted for potential confounders. Results The cohort was 90% (36/40) male with mean age 57 ±12 years. The median HF duration was 50 months. From baseline to 6 months, there was a significant increase in KCCQ scores (baseline: 46.6 ±19.0, n=40; 3 months: 65.4 ±18.3, n=35, p Conclusion Among patients with advanced HF, skeletal muscle mass and patient-reported health status are positively associated and both significantly increase over the first 6 months of LVAD support. While muscle strength does not significantly change with time, it is significantly associated with patient-reported health status. Further research is necessary to fully evaluate the significance of restoring muscle mass and function to optimize patient-reported QoL.

Multicenter Study of Favorable Patient Characteristics Associated with Cardiac Reverse Remodeling in Left Ventricular Assist Device Patients

<h3>Purpose</h3> This study analyzed a multicenter cohort of patients who underwent left ventricular assist device (LVAD) implantation to distinguish favorable characteristics that increase the likelihood for cardiac reverse remodeling and myocardial recovery. <h3>Methods</h3> This was a multicenter study at 4 LVAD implanting sites in the U.S. Baseline patient characteristics, including demographics, medical history and echocardiographic parameters were reviewed. Echocardiographic parameters of LV structure and function were obtained pre-implant and at 1, 3, 6, and 12 months of LVAD support. Responders to LVAD therapy had echocardiographic evidence of reverse cardiac remodeling and achieved an LVEF ≥ 40% and LV ventricular internal diastolic diameter (LVIDd) ≤ 6.0cm. Univariate and multivariate analyses were performed to determine the odds ratio of achieving responder status. <h3>Results</h3> The study retrospectively reviewed 311 chronic HF patients receiving LVAD support. The average patient age was 55.6 ± 12.9 years, 17.7% were female, 53% had an ischemic cardiomyopathy, and the average duration of HF was 3.4 ± 3.0 years pre-implant. In the cohort, 9.32% of patients achieved responder status. Univariate analysis of baseline characteristics was performed to identify predictors of responder status at final echocardiographic time point. Female sex and age ≤ 65 years had improved odds of myocardial recovery (OR 2.31, 95%CI: 1.0 to 5.4, p=0.05 and 2.26, 95%CI: 1.03 to 4.98, p=0.04). Other significant predictors of cardiac reverse remodeling are presented in the figure. In a multivariate analysis, female sex, age ≤ 65 years and an LVIDd ≤ 7.3cm were each individually associated with a 2-fold increase in the odds of cardiac reverse remodeling. <h3>Conclusion</h3> In a contemporary, multicenter study of LVAD patients, we identified a combination of baseline clinical and echocardiographic characteristics associated with significant cardiac reverse remodeling during LVAD support.

Serum Protein Levels as Biomarkers of Muscle Strength in Patients with End-Stage Systolic Heart Failure

Purpose Patients with heart failure (HF) are at increased risk of unintentional weight loss, principally loss of skeletal muscle mass, which may exacerbate patients’ impairments in physical functioning. Serum protein levels have been proposed as biomarkers of cardiac cachexia based upon their purported relationship with protein balance and nutritional status. However, it is not known whether the serum protein markers albumin and prealbumin are related to muscle strength and dietary protein intake in patients with HF. Methods We retrospectively analyzed a dataset prospectively collected between 5/2016-3/2020 from patients with end-stage systolic HF ±21 days from left ventricular (LVAD) implantation. Each visit included venous blood draw for serum albumin and prealbumin levels, hydraulic hand dynamometer for handgrip strength and dietary protein intake collection for 3 days followed by analysis in the Food Processor® software. All data collection was repeated at 3 and 6 months after LVAD implantation (±14 days), with study participation ending after either the 6 month visit or heart transplantation, whichever occurred first. Pearson correlations and linear mixed effects models were constructed using SAS and adjusted for 24-hour averaged protein intake. Results The cohort was 89.7% (35/39) male, with mean age 57±11.6 years. There was a positive correlation between baseline albumin levels and baseline handgrip strength (r=0.48, p=0.002, n=38), but no correlation between baseline prealbumin levels and handgrip strength (r=0.01, p=0.94, n=38). There was a positive association across all data for albumin and handgrip strength (n=90 values, p Conclusion In patients with HF undergoing left ventricular assist device (LVAD) evaluation, serum albumin levels could be used as a biomarker of muscle strength, independent of the dietary protein intake. Serum albumin and prealbumin levels do change over the medium-term, showing a stepwise increase at 3 and 6 months of LVAD support, with the greatest increase during the first 3 months.

Abstract 16239: Skeletal Muscle Mass Recovery Early After Left Ventricular Assist Device Implantation in Patients With Advanced Systolic Heart Failure

Introduction: Patients with advanced systolic heart failure (HF) are at risk of unintentional weight loss and muscle wasting. It has been observed that left ventricular assist device (LVAD) recipients gain weight after device implantation, although it is unknown whether this represents skeletal muscle or fat mass gains. Hypothesis: We hypothesized that LVAD recipients would gain skeletal muscle mass during the first 6 months of LVAD support. Methods: We prospectively recruited 28 adults with systolic HF ±21 days from LVAD implantation. Participants underwent whole-body dual X-ray absorptiometry (DXA) to calculate fat free mass (FFM, representing all lean mass), appendicular lean mass (ALM, lean mass in the arms and legs) and fat mass (FM). DXA was repeated at 3 and 6 months after LVAD implantation (±14 days), with study participation ending after either the 6 month visit or heart transplantation, whichever occurred first. Paired t-testing and mixed effects models were used to evaluate changes over time each for FFM, ALM and FM. Results: The cohort was 86% (24/28) male, with mean age 56 ±12 years and mean BMI 26.6 ±5.5 kg/m 2 at baseline. The median Intermacs class was 2 and duration of HF 50 months. Per European Working Group on Sarcopenia in Older People (EWGSOP) criteria, 41% of participants had muscle wasting at baseline. There was a significant increase from baseline to 3 months and then 6 months of LVAD support for FFM (Fig 1A; baseline: 56.6 ±11.8 kg, n=27; 3 months: 57.9 ±11.3 kg, n=23; 6 months: 62.7 ±11.1 kg, n=17; p-value for change=0.025) and for ALM (Fig 1B; 22.2 ±5.6 kg; 23.2 ±5.0 kg; 25.4 ± 4.5 kg; p&lt;0.001). There was no increase in FM over the same period (p=0.36). Amongst 22 participants with comparison DXAs, 81% had a ≥5% ALM gain by either 3 or 6 months. Conclusions: Among patients with advanced systolic HF and a high baseline prevalence of muscle wasting, there was a significant gain in skeletal muscle mass, as represented by both FFM and ALM, over the first 6 months of LVAD support.

Aspirin Sensitivity Wanes Early during Left Ventricular Assist Device Support

Aspirin (ASA) therapy is recommended in left ventricular assist device (LVAD) patients to prevent thromboembolic complications. Up to 30% of LVAD patients may demonstrate ASA resistance, which has been related to thrombotic complications. However, it is unknown whether individual patients exhibit temporal alterations in ASA sensitivity during LVAD support. This project evaluated changes in ASA platelet inhibition over the first 6 months of LVAD support. We hypothesized that ASA platelet inhibition would wane after the initial post-implant period. Patients who underwent placement of Heartware or Heartmate III LVAD at our institution and had serial ASA platelet sensitivity assays were included for analysis. ASA responsiveness was determined by VerifyNow assay with results expressed in aspirin reactivity units (ARU). ASA platelet resistance was defined by ARU greater than 550. ASA responsiveness was assessed post-implant after 5 days, 3 months, and 6 months. Out of 28 patients included for analysis only 7% were ASA-resistant at baseline. However, 32% of patients were ASA-resistant at 3 months and 28% at 6 months. (Figure 1). ASA-resistance was significantly more prevalent at 3-months (OR 6.1, p=0.03) with a trend toward increased prevalence at 6 months (OR 4.1, p=0.1) compared to early post-implant. ASA dose was increased in 4% and 14.3% of ASA-resistant patients at 3 and 6 months, respectively. ASA responsiveness not only varies between patients, but can significantly change within individual LVAD patients over time. Over the first 3 months, the odds of ASA-resistance increased 6-fold and remained relatively constant at 6 months despite aspirin dose adjustment. Serial assessment of ASA responsiveness may help better identify LVAD patients at risk for thrombotic or bleeding complications. Further study is required into the both the clinical implications and the mechanism of waning aspirin sensitivity in LVAD patients.

Magnitude and Time Course of Left Atrial Remodeling Changes in Patients Undergoing Chronic Left Ventricular Assist Device Support

Although left ventricular (LV) reverse remodeling has been described in patients with left ventricular assist devices (LVADs), little is known about left atrial (LA) structural and functional changes. Echocardiographic parameters were obtained at pre-LVAD implant and following 1, 3, and 6 months of LVAD support. Favorable LV structural and functional response following LVAD support (i.e. Responders) was defined using previously published criteria. Structural and functional indices specific to LA such as LA volume index (LAVI) and LA total emptying fraction (LATEF) were compared in eighteen Responders versus twenty Non-Responders. Statistical comparison of quantitative data was performed using 2-tailed Wilcoxon signed-rank test for paired samples and categorical data were compared using Fisher's exact test. The magnitude and time course of functional changes as reflected by the LVEF and LATEF in Responders and Non-Responders are depicted in Figure 1A and 1B. LA remodeling structural changes over time in Responders and Non-Responders are depicted in Figure 1C. Patients experiencing post-LVAD favorable LV functional response had significantly better LA remodeling structural and functional indices before LVAD implantation and further improved those early after the initiation of LV mechanical support. LA reverse remodeling studies with longer follow-up and correlation with post LVAD-weaning patient outcomes are warranted.

Global Geographical Variation in Rates of Cardiac Recovery and Left Ventricular Assist Device Explantation in Chronic Heart Failure: Insights from the International Registry for Mechanically Assisted Circulatory Support

There is limited information on regional variation in rates of cardiac recovery and left ventricular assist device (LVAD) explantation at a global level. We aimed to compare the rates of cardiac recovery and LVAD explantation across several world regions. LVAD recipients registered in the International Registry for Mechanically Assisted Circulatory Support (IMACS) were analyzed. Cardiac recovery was defined as follow-up LVEF >40% and a pre-LVAD LVEF <30%. Cardiac recovery and LVAD explantation/deactivation due to recovery were evaluated in bridge-to-recovery (BTR) and non-BTR designation patients in the Americas, Asia-Pacific and Europe. A total of 16,029 patients met our inclusion criteria and were included in the analysis. Of these, 9,381 patients had at least one follow-up echocardiogram and a minimum of 3 months of LVAD support. Cardiac recovery was achieved in 13.3% (n=1,249) of patients, with a rate of 55.3% (n=21) in BTR compared with 13.1% (n=1,228) in non-BTR patients. Rates of cardiac recovery varied significantly by region: 12.7% (n=1,079) in the Americas, 15.9% (n=94) in Asia-Pacific and 29.5% (n=76) in Europe (p<0.001) (Figure 1A). Rates of LVAD explantation/deactivation were similar between the Americas (5.7%) and Asia-Pacific (4.6%) and lower in Europe (2.0%) (p<0.001) (Figure 1B). Global rates of both cardiac recovery and LVAD explantation are higher in patients implanted with a priori BTR strategy. Rates of cardiac recovery appear to be higher in Europe for reasons that warrant further investigation. The global rates of LVAD explantation are much lower compared to the corresponding cardiac recovery rates. This observation invites future investigations to identify the challenges in regards to LVAD weaning when recovery is identified, which could result in higher rates of LVAD explantation.

Optimal Mechanical Unloading in Left Ventricular Assist Device Recipients Relates to Progressive Up-Titration in Pump Speed

Left ventricular (LV) assist devices (LVADs) are known to elicit reverse remodeling by mechanically unloading the left ventricle. Current guidelines target a reduction in LV end-diastolic diameter (LVEDD) of15% compared with pre-LVAD dimensions; however, there is significant heterogeneity in the degree of unloading achieved. We sought to investigate factors associated with mechanical unloading at 6months of LVAD support. Data were retrospectively collected for 75 LVAD recipients at five time points: pre-LVAD, within 14days post-LVAD, and at 1, 3, and 6months post-LVAD. The percentage change in LVEDD between the pre-LVAD and 6months post-LVAD time points was termed ΔLVEDD. Optimal LV unloading was defined as ΔLVEDD of ≥15% at 6months. Patients who achieved optimal unloading (group A, n=30) were compared with patients who did not (group B, n=45). At 6months, optimally unloaded patients (group A) demonstrated higher fractional shortening (15%±10% vs 10%±7%, P=.007), lower rates of moderate or severe mitral regurgitation (10% vs 33%, P=.02), and lower pulmonary capillary wedge pressure (9±4 vs 16±7mm Hg, P=.02). Right ventricular dysfunction was more prevalent at 6months in poorly unloaded (group B) patients (73% vs 43%, P=.008). Between hospital discharge and 6months, the percentage increase in pump speed (Δ revolutions per minute) washigher in group A patients (4.4%±3.7% vs 0.1%±2.6%, P<.001). In a multivariate analysis, Δ revolutions per minute and tricuspid annular systolic velocity (S') at 6months were independently associated with 6-month ΔLVEDD. Recipients of LVADs who undergo progressive pump speed up-titration during outpatient follow-up are more likely to sustain optimal LV unloading. Progressive LVAD-related right ventricular failure is prevalent in suboptimally unloaded patients.

Macro- and Micronutrient Dietary Quality in Patients with Advanced Systolic Heart Failure Receiving Left Ventricular Assist Devices

Introduction Macro- and micronutrient insufficiencies are common in patients with ambulatory systolic heart failure (HF) and are associated with adverse clinical outcomes. Less is known about dietary quality in advanced systolic HF, particularly the adequacy of protein intake. It is also unknown if dietary quality improves during mechanical support and so we sought to determine nutrient intake changes early after left ventricular assist device (LVAD) implantation. Methods We recruited adults with advanced systolic HF ±21 days from LVAD implantation. Weight and appendicular lean mass (ALM) were assessed by whole-body dual X-ray absorptiometry (DXA). Food intake was assessed with 3-day facilitated food records and entered into the Food Processor Nutrition Analysis Software. Study procedures were repeated after 3 months ±14 days of LVAD support. The Institute of Medicine's Estimated Average Requirement values (EARs, age and sex-specific ranges) were tabulated beside the median (quartile 1-3) results from the baseline and 3-month food records.Comparisons were made between baseline and 3-month intakes using Wilcoxon matched-pairs signed rank tests. Results The cohort (n=18) was 78% male, with median age 60 years, weight 77.5 kg, BMI 25.2 kg/m2 and serum albumin 3.4 g/dL. Baseline dietary quality was poor as compared to general population EARs (Table 1), with a high prevalence of vitamin A, B1, B6, D, E, folate, calcium, magnesium, zinc and selenium insufficiencies. Protein supplementation products were used by 78% at baseline and 39% at 3 months. Despite no changes in average daily calorie or carbohydrate intake from baseline to 3 months, and only a non-significant upward trend in protein and fat intake, there was an increase in total body weight and appendicular lean mass (Table). Micronutrient intakes did not significantly improve at 3 months, and intake of calcium and vitamin D decreased. Conclusions Baseline micronutrient dietary quality was poor amongst patients with systolic HF undergoing LVAD implantation. Micronutrient changes at 3 months were variable, with some intakes including calcium and vitamin D decreasing, possibly secondary to reduced use of supplementation products after the LVAD implantation hospitalization. Protein intake was sufficient per estimated average requirements and non-significantly trended upwards during the first 3 months of LVAD support.

Characterizing Sex-Specific Baseline Characteristics and Outcomes in Left Ventricular Assist Device (LVAD) Support

Purpose Women are underrepresented in the patient population who receive left ventricular assist devices (LVAD) as a therapy for advanced heart failure (HF). A limited number of studies suggest greater adverse outcomes in women on LVAD support than in men. This study aims to expand the sex-based data on the growing female LVAD population. Methods Single-center retrospective of 25 women and 126 men in their first 12 months of LVAD support were analyzed using IBM SPSS Statistics V. 24.0. Adverse events were categorized using the INTERMACS Appendix. Results The mean ages for female and male patients were 48.0 ± 18.0 and 57.0 ± 12.0 years, respectively (p = 0.002). Women were more likely to be listed for heart transplant prior to LVAD implantation (76% vs 54%, p = 0.042), the etiology of HF was more often non-ischemic in origin (79% vs 52%, p = 0.013) and Cr was lower (1.0 vs 1.4 mg/dL, p = 0.001). No other statistically significant differences existed at baseline between the two cohorts, including baseline NYHA class, INTERMACS status, BMI, type of LVAD device, or medications prior to implant. There were no significant differences in outcomes including readmission, bleeding, infection, neurological events, or right heart failure within the first year. Time to first neurological event was longer in women (7 months vs 2 months, p = 0.008). There was no difference in risk of death in the first year. Conclusion Although younger and non-ischemic, women with LVADs experience similar first year outcomes as men.

Impact of Early Weight Changes after Left Ventricular Assist Device Implantation on Subsequent Survival

Background Left ventricular assist device (LVAD) candidates commonly experience unintentional weight loss (cardiac cachexia) pre-implantation. Cardiac cachexia is associated with mortality, but patients may regain lost weight once supported by an LVAD. We sought to characterize early post-LVAD weight changes, define the impact of early weight gain on survival, and identify pre-LVAD biomarkers of subsequent weight gain failure. Methods We reviewed single-center durable LVAD recipients 2010-2015, recording percent weight change (WC) from implantation to 3 and 6 months of LVAD support (±14 days). We constructed a Cox model, starting at 3 months, for the relationship between WC and mortality on LVAD support (censored on transplant). We used linear regression to identify pre-LVAD laboratory variables associated with positive WC at 3 months post-LVAD. Results Of 211 LVAD recipients, 166 survived on LVAD support >3 months and were eligible for analysis (21% female, mean age 55 y, BMI 27.9 kg/m 2 ). Pre-LVAD BMI was not associated with subsequent mortality. The mean WC at 3 and 6 months was -2.97% (±std dev 8.66%) and +1.69% (±10.72%), respectively ( Figure 1a ), with 23% and 47% of patients achieving ≥+3% WC at 3 and 6 months. Patients with pre-LVAD BMI 2 were more likely to gain ≥+3% weight than those with pre-LVAD BMI ≥25 kg/m 2 at 3 months (44% vs 11%, p Figure 1b ). Positive WC at 6 months showed a similar association: adjusted HR 0.92, 95% CI 0.88-0.96, p Conclusion Mean weight declines early post-LVAD, followed by subsequent weight recovery at 6 months of LVAD support. A positive WC at 3 or 6 months is associated with greater future survival. Low albumin and high NLR at LVAD implantation may identify recipients at risk of weight gain failure, who could be targeted for an early nutritional intervention.

Can a Left Ventricular Assist Device in Individuals with Advanced Systolic Heart Failure Improve or Reverse Frailty?

Frailty, characterized by low physiological reserves, is strongly associated with vulnerability to adverse outcomes. Features of frailty overlap with those of advanced heart failure, making a distinction between them difficult. We sought to determine whether implantation of a left ventricular assist device (LVAD) would decrease frailty. Prospective, cohort study. Five academic medical centers. Frail individuals (N = 29; mean age 70.6 ± 5.5, 72.4% male). Frailty, defined as having 3 or more of the Fried frailty criteria, was assessed before LVAD implantation and 1, 3, and 6 months after implantation. Other domains assessed included quality of life, using the Kansas City Cardiomyopathy Questionnaire; mood, using the Patient Health Questionnaire; and cognitive function, using the Trail-Making Test Part B. After 6 months, three subjects had died, and one had undergone a heart transplant; of 19 subjects with serial frailty measures, the average number of frailty criteria decreased from 3.9 ± 0.9 at baseline to 2.8 ± 1.4 at 6 months (P = .003). Improvements were observed after 3 to 6 months of LVAD support, although 10 (52.6%) participants still had 3 or more Fried criteria, and all subjects had at least one at 6 months. Changes in frailty were associated with improvement in QOL but not with changes in mood or cognition. Higher estimated glomerular filtration rate at baseline was independently associated with a decrease in frailty. Frailty decreased in approximately half of older adults with advanced heart failure after 6 months of LVAD support. Strategies to enhance frailty reversal in this population are worthy of additional study.

Effective Illustration of Decommissioning of Left Ventricular Assist Device after Bridge-to-Recovery by Hybrid Minimally-Invasive Tactic: Anesthesia Substances

We report successful decommissioning of HeartWare left ventricular assist device (LVAD) (HVAD, HeartWare Inc., Framingham, MA) leaving the pump in situ by hybrid percutaneous approach. In this case, the indication for mechanical assist device separation was myocardial recovery, which occurred following 19 months of LVAD support. Anaesthetic goals include maintenance of sinus rhythm, avoidance of myocardial depression and increase in systemic vascular resistance (SVR), with optimal blood pressure control, normothermia, and judicious fluid management. Intraoperative assessment of suitability to wean using transesophageal echocardiography (TEE) and continuous cardiac output monitoring with pulmonary artery catheter must be expedient as no anticoagulation is given. This case report demonstrates the feasibility of separating a patient from a LVAD without the need for a major re-operative intervention.