Predicting Outcomes in LVAD Recipients
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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:
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
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