Slaughter, Mark S.

ImportanceThe advanced ambulatory heart failure (HF) population comprises patients who have progressed beyond the pillars of recommended stage C HF therapies but can still find meaningful life-years ahead. Although these patients are commonly encountered in practice, national databases selectively capture the small groups accepted for heart transplant listing or left ventricular assist devices. The epidemiology, trajectories, and therapies for other ambulatory patients with advanced HF are poorly understood.ObservationsIn December 2022, the National Heart, Lung and Blood Institute convened a team of experts to identify knowledge gaps and research priorities for the ambulatory population with limiting daily symptoms and transition toward refractory end-stage D HF, designated as stage C2D. This article summarizes the findings from that 3-day workshop. Workshop participants surveyed the initial challenges and knowledge gaps for (1) recognition of ambulatory C2D HF, (2) estimation of the magnitude of the affected population and identifiable subpopulations, and (3) physiologic phenotypes, such as low cardiac output, right HF, cardiorenal syndromes, congestive hepatopathy and frailty, which offer distinct targets for existing and emerging therapies. Social drivers of HF and patient preferences for quality/length of survival were highlighted as essential modifiers for personalization of therapies.Conclusions and RelevanceTen key points summarized workshop findings, with target cohorts for study proposed as a crucial next step. This workshop summary is intended as a call for action to address knowledge gaps and develop new strategies to improve outcomes in the large ambulatory population with C2D HF.

Introduction: Advanced age is a risk factor for poor outcomes following left ventricular assist device (LVAD) implant. A means of identifying elderly patients with acceptable mortality risk following LVAD surgery is not currently available. The HeartMate II (HMII) Risk Score (HMRS) was recently developed and validated, providing good risk discrimination for predicting survival in patients undergoing HMII implant. Independent survival predictors in the model included age and markers of renal function, coagulopathy and nutrition. We hypothesize that the HMRS will provide utility for risk stratification of the elderly LVAD candidate. Methods: Elderly patients (age >65 years) enrolled into the HMII Destination Therapy (DT) and Bridge to Transplant trials were selected for the study (n=444). Complete data for HMRS calculation was available in 98% (n=435). Preoperative patient HMRS was calculated according to the formula: HMRS = ln(1.29)*decade of age + ln(0.71)*Albumin + ln(1.37)*Cr + ln(1.86)*INR + ln(0.52)*LVAD Center Volume >=15 + ln(0.67)*Implant after 2007. Patients were trichotimized into high (HMRS >1.0), medium (HMRS 0.50-1.0), and low (HMRS <=0.50) risk categories (as previously defined in model development) based on HMRS. The primary endpoint was survival at 1 year following LVAD implant, estimated using Kaplan-Meier methods. Results: The mean cohort age was 71±4 years and 84% (n=372) had devices implanted for DT. The table shows the HMRS along with mean±stddev values for the score's components. All between-group differences were statistically significant (Kruskal-Wallis p<0.05), although differences in age were not clinically significant. Survival based on HMRS strata is shown in the figure. Patients in the low and medium risk groups had survivals >80% at 1 year following LVAD implant. Conclusions: The HMRS can be used to identify elderly patients with survivals comparable to that of the general LVAD population.

Introduction: Cardiac arrhythmias are common in continuous flow left ventricular assist device (LVAD) recipients. The impact of axial vs. intrapericardial centrifugal LVAD pumps on arrhythmia incidence and associated clinical outcomes is unclear. Hypothesis: This multicenter study evaluated the impact of LVAD type (axial vs. centrifugal) on incidence of atrial and ventricular arrhythmias, ICD shocks and mortality in LVAD patients. Methods: Analysis was done on 536 patients who underwent LVAD implantation at 5 US centers from 2008 to 2016. The groups were divided based on their LVAD type (axial - HeartMate II [HMII, n=433] vs. centrifugal - HeartWare (HW, n=103). Baseline characteristics as well as incidence of post-LVAD atrial arrhythmias (PL-AA), ventricular arrhythmias (PL-VA) and ICD shocks were analyzed in these groups. Multivariable Cox Regression analysis was used to identify predictors of survival. Results: Of 536 patients, 433 had HMII axial LVAD and 103 had HW centrifugal VAD implant. At baseline, HMII group had more males, higher proportion of CRT-D and higher prevalence of AA (Table 1A). Left ventricular dimensions were similar between groups. During a median follow-up of 537 days of LVAD support, incidence of PL-VA and ICD shocks were significantly higher in the HM2 group compared to HW group whereas incidence of PL-AA was not significantly different (Table 1A). In multivariable Cox Regression analysis, LVAD indication was the only variable that predicted survival (Table 1B). Type of LVAD (axial vs. centrifugal) was not associated with survival (HMII vs. HW - HR 1.04, P=0.48). Conclusions: In this multi-center continuous flow LVAD cohort, axial HM2 VAD patients had a higher incidence of PL-VA and ICD shocks. Type of LVAD (axial vs. centrifugal) was not associated with survival.