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LVADs have revolutionized the care of end-stage heart failure patients. Utilizing block-group census data to characterize neighborhood-level socioeconomic status(nSES), we set out to examine the effect of nSES & public versus private insurance status with respect to overall mortality and readmission. We performed a retrospective review of LVAD recipients bet. Jun 2006 & Dec 2016 at the Ohio State University Wexner Medical Center (n=239). Primary outcomes were time to death and time to readmission. Patients' demographics are shown in Table 1. Patients on public insurance displayed a higher hazard of death post-LVAD compared to private insureds (Fig. 1; log-rank p=0.0004). Medicaid, Medicare, and Medicaid-Medicare dual-enrollment were significant independent predictors of death, with an associated ≥3 fold hazard of death. TR of varying severity was also a significant independent predictor of mortality (Table 2). Median household income (MHI) was not associated with any primary outcomes. LVAD recipients on public insurance were at higher mortality risk compared to private insureds. Block-group level MHI failed to predict mortality and 1 year readmission for these patients. More work is needed to properly contextualize the SES impact on LVAD outcomes. [ABSTRACT FROM AUTHOR]

Deciding which patients can be weaned from an RVAD placed after LVAD implantation could help triage advanced heart failure device strategy. Therefore, we set out to determine the predictors of RVAD weaning. A multi-center retrospective study of 826 consecutive patients who received either a HeartMate2 or HVAD between 1/2007 an 12/2007. We identified 91 patients who received an early RVAD insertion during their LVAD implant index admission. A Cox Proportional hazard model was constructed to identify predictors of RVAD weaning. There were 91 patients (11%) who required an RVAD after LVAD with 48 (52%) weaned from RVAD support and 43 (48%) not weaned. Patients who were weaned had a lower prevalence of hypertension, higher pre-operative ACE-inhibitor use, and lower pre-operative transpulmonary gradient (TPG), RA-PCWP ratio, and RVSWI; they were also more likely to receive concomitant RVAD at time of LVAD insertion and ultimately transplanted more often (Table 1). Our multivariable model for predictors of RVAD weaning included pre-operative creatinine (HR 0.32 [0.15, 0.70], p = 0.004), PVR (HR 1.23 [1.02, 1.48], p = 0.03), non-white ethnicity (HR 2.56 [1.19, 5.54], p = 0.02), COPD (HR 4.63 [1.32, 16.25], p = 0.02), and concomitant RVAD insertion (HR 2.87 [1.00, 8.21], p-value = 0.05) with a model c-statistic of 0.84. The survival curve demonstrates that patients who are weaned from RVAD have significantly improved 1-year mortality (Figure 1, p < 0.001). In a multi-institutional continuous-flow LVAD cohort, we show novel predictors of RVAD weaning that can help triage mechanical support strategy. [ABSTRACT FROM AUTHOR]

Prediction of right heart failure (RHF) after left ventricular assist device (LVAD) implant is a crucial step to improve outcomes. The EUROMACS Right-Sided Heart Failure (EUROMACS-RHF) risk score is one of the most recent derived scores for RHF prediction after LVAD but it lacks external validation. The aim of our study was to validate the EUROMACS-RHF risk score. From 01/2007 to 12/2017, 878 continuous-flow LVADs were implanted at three tertiary care centers. We calculated the EUROMACS-RHF score in 662 patients with complete data. We evaluated the predictive performance of the score for early RHF defined as need for short- or long-term right-sided circulatory support, continuous inotropic support for ≥14 days or nitric oxide ventilation for ≥48 hours post-operatively. RHF occurred in 211 patients (32%). RHF patients had higher creatinine, bilirubin and right atrial pressure, more echocardiographic RV dysfunction and were more critically ill reflected in lower INTERMACS class (p<0.05). Length of stay and in-hospital mortality were higher in patients with RHF. Area under the ROC curve for RHF prediction of the EUROMACS-RHF score was 0.64 (95% CI 0.60-0.68), and slightly higher for the right ventricular assist device implantation component RHF definition [0.67 (95% CI 0.61-0.74)]. Risk discrimination of the score was significantly better than for other three previous published scores and reclassification of patient risk improved when the EUROMACS-RHF score was applied. Patients in the high-risk category according to the EUROMACS-RHF score had also significantly higher in-hospital and 2-year all-cause mortality. In an external validation, the EUROMACS-RHF had similar discrimination predicting RHF compared to the original derivation cohort, which was better than other published scores. The clinical utility of these scores in the decision to implant LVAD in prospective studies remains to be determined. [ABSTRACT FROM AUTHOR]

Early insertion of an RVAD may help to mitigate post-LVAD implantation morbidity and mortality. We hypothesize that concomitant RVAD insertion at time of LVAD implantation improves 1-year mortality in comparison to post-operative insertion. A multi-center retrospective study of 826 consecutive patients who received either a HeartMate2 or HVAD between 1/2007 an 12/2017. We identified 91 patients who either had an unplanned or planned early RVAD on index admission. A Cox proportional hazard model was constructed to identify predictors of 1-year mortality. There were 91 patients (11%) who required an RVAD after LVAD implantation with 51 (56%) receiving a concomitant RVAD and 40 (43%) post-operatively (Table 1). Concomitant RVAD with LVAD insertion was associated with lower mortality (HR 0.45 [0.27, 0.76], p-value = 0.002, Figure 1). Our multivariable model (which included age, BMI, and ACE-i use) found receiving transplant (HR 0.04 [0.01, 0.29], p = 0.001) and concomitant RVAD (HR 0.51 [0.29, 0.90], p = 0.004) to be independent predictors of 1-year mortality with a final model C-statistic of 0.77. Stratifying concomitant RVAD by intended approach, planned versus unplanned RVAD insertion had a similar survival rate as unplanned approach at 1 year (42.8% versus 28.6%, p-value = 0.08). We show in a continuous-flow and multi-institutional cohort that concomitant RVAD insertion at time of LVAD is associated with improved survival at 1 year compared to post-operative insertion. [ABSTRACT FROM AUTHOR]

Preoperative post-LVAD RVF predictive models have moderate discrimination. We hypothesize that machine learning using unsupervised k-type phenotyping can identify homogenous subclasses of patients in this heterogenous population. A multi-center retrospective study of 826 consecutive patients who received either a HeartMate2 or HVAD between 1/2007 and 12/2016. After removing outliers, 816 patients were clustered using an unsupervised k-type approach with the following 10 variables: mean PA pressure (mPAP), hemoglobin (Hg), absolute neutrophil count (ANC), absolute lymphocyte count, CVP/PCWP ratio, age, INTERMACS profile, transpulmonary gradient, body mass index (BMI), and cardiac index (CI). Characteristics associated with cluster membership were assessed using a multinomial logistic regression. Three clusters were identified. Cluster 1 had a mean age of 53 years old, INTERMACS profile ≥ 3 (70%), borderline hemodynamics, normal labs and BMI. Factors associated with Cluster 2 membership included older age (RRR 1.09, 95% CI 1.03-1.16), elevated BMI (RRR 1.25, 95% CI 1.13-1.38), low INTERMACS profile ≥ 3 membership (RRR 0.04, 95% CI 0.01-0.21), low Hg (RRR 0.23, 95% CI 0.15-0.37), elevated ANC (RRR 2.07, 95% 1.36-3.14), high diastolic pulmonary gradient (DPG) (RRR 1.26, CI 1.10-1.45) and PVR (RR 2.06, CI 1.52-2.80). Cluster 3 membership was defined by old age (RRR 1.29, 95% CI 1.18-1.41), high ANC (RRR 2.45, 95% CI 1.57-3.83), normal CI (RRR 18, 95% CI 4.7-69.3), lower BMI (RRR 0.75, 95% CI 0.65-0.86) and hemoglobin (RRR 0.12, 95% 0.06-0.23). Cluster memberships stratified receipt of unplanned RVAD or death from RVF during index admission (Cluster 1: 5.1% [ref], Cluster 2: 17.4% [OR 8.85, 95% CI 12.14-7.38], p < 0.001], Cluster 3: 9.5% [OR 1.98, 95% CI 1.03-3.80, p = 0.04) and one-year survival (Figure 1). We show three distinct patient phenotypes who develop post-LVAD RVF. Therapy targeting these patient groups could help mitigate RVF. [ABSTRACT FROM AUTHOR]