Predicting Outcomes in LVAD Recipients

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April Willis
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1 Predicting Outcomes in LVAD Recipients Sean P. Pinney, MD Director, Advanced Heart Failure & Cardiac Transplantation Professor of Medicine, Cardiology Icahn School of Medicine at Mount Sinai New York, NY March 8,

2 Disclosure CareDx: speaking honoraria, consulting fees Thoratec, St. Jude, Abbott: consulting fees, honoraria 2

3 INTERMACS Patient Profiles Profile Shorthand Description Time to MCS 1 Crashing & burning Critical cardiogenic shock patient who has life-threatening hypotension and rapidly escalating inotropic pressor support Within hours 2 Progressive decline 3 Stable but inotrope dependent 4 Resting symptoms A patient who has been demonstrated dependent on inotropic support but nonetheless shows signs of continuing deterioration A patient who is clinically stable on mild-moderate doses of intravenous inotropes A patient who is at home on oral therapy but with frequent symptoms of congestion at rest or with any activities of daily living Within a few days Within a few weeks Within weeks to months 5 Exertion intolerant A patient who is comfortable at rest but unable to engage in any activity, living predominantly within the house or household, but without overt congestion Variable 6 Exertion limited A patient who is comfortable at rest without evidence of fluid overload and able to do some mild activities of daily living, but gets fatigued within a few minutes of any meaningful exertion Variable 7 Advanced NHYA class III Clinically stable patient with a reasonable level of comfortable activity, despite history of previous decompensation that is not recent Not a candidate 3

4 4

5 INTERMACS Profiles: Eye of the beholder? Cowger J et al. J Heart Lung Transplant 2016;35:

6 Profile Demographics: real differences Cowger J et al. J Heart Lung Transplant 2016;35:

HeartMate Risk Score (HMRS) HMRS = (0.0274 x [age in years]) - (0.723 x [albumin g/dl]) + (0.74 x [creatinine mg/dl]) + (1.

7 HeartMate Risk Score (HMRS) HMRS = ( x [age in years]) - (0.723 x [albumin g/dl]) + (0.74 x [creatinine mg/dl]) + (1.136 x [INR]) + (0.807 x [center LVAD volume 15*]) Low = < 1.58 Medium = High = > 2.48 Cowger J et al. J Am Coll Cardiol 2013;61:

8 HMRS Observed 90-day Mortality Cowger J et al. J Am Coll Cardiol 2013;61:

9 Survival Stratified by HMRS Cowger J et al. J Am Coll Cardiol 2013;61:

10 Short- and Long-term Survival Stratified by HFRS Adamo L et al. J Am Coll Cardiol HF 2015;3:

11 INTERMACS 1 Survival Stratified by HFRS Adamo L et al. J Am Coll Cardiol HF 2015;3:

12 HMRS Within and Across INTERMACS Profiles Adamo L et al. J Am Coll Cardiol HF 2016;4:

13 HMRS + INTERMACS Adamo L et al. J Am Coll Cardiol HF 2016;4:

14 HMRS in ROADMAP LVAD Arm Lanfear DE et al. Circ Heart Fail 2017;10:e

15 Bayesian Network-Based Risk Stratification Model Loghmanpour NA et al. ASAIO J 2015;61:

16 Bayesian Network-Based Risk Stratification Model Loghmanpour NA et al. ASAIO J 2015;61:

17 Loghmanpour NA et al. ASAIO J 2015;61:

18 LVAD Is there an age limit? 18

19 LVAD Survival by Age Groups Kirklin JK et al. J Heart Lung Transplant 2013;32:

20 Kirklin JK et al. J Heart Lung Transplant 2015;34:

21 Impact of Age On MOMENTUM-3 Outcomes Goldstein DJ et al. J Heart Lung Transplant 2018;37:

22 Exterkate L et al. Transplantation 2016;100: Frailty

23 Frailty Impacts VAD/OHT-Free Survival Jha SR et al. J Heart Lung Transplant 2016;35:

24 Frailty Negatively Impacts VAD Survival Jha SR et al. J Heart Lung Transplant 2016;35:

25 Living Well on an LVAD Cowger JA et al. J Heart Lung Transplant 2018;37:

26 Correlates of Living Well on an LVAD Cowger JA et al. J Heart Lung Transplant 2018;37:

27 Summary INTERMACS profiling is useful for stratifying risk in advanced HF populations Statistical-based classifier scores (HMRS) have reasonably good discrimination and calibration Network-based models (Baysian) better characterize patient outcomes Need for improved predictive models of long-term outcomes especially in non-inotrope dependent pts Frailty is an increasingly important predictor of VAD outcome 27

28 The Mount Sinai Hospital 28

LVADS IN AMBULATORY PATIENTS CLASS III PATIENT SHOULD UNDERGO LVAD IMPLANTATION

LVADS IN AMBULATORY PATIENTS CLASS III PATIENT SHOULD UNDERGO LVAD IMPLANTATION Ajith Nair MD Baylor College of Medicine / Texas Heart Institute American Association for Thoracic Surgery Mechanical Circulatory