Are we ready to implant LVAD’s in the less sick? Ileana L. Piña, MD, MPH Professor of Medicine and Epi/Pop Health Albert Einstein College of Medicine Associate.

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Presentation transcript:

Are we ready to implant LVAD’s in the less sick? Ileana L. Piña, MD, MPH Professor of Medicine and Epi/Pop Health Albert Einstein College of Medicine Associate Chief for Academic Affairs, Montefiore-Einstein Medical Center Consultant, FDA, CDRH, ODE

INTERMACS

Do we have equipoise? Smaller pumps, less intrusive Less invasive surgery Better survival with continuous flow pumps Improves HRQoL Known poor HRQoL in most NYHA Class III-IV Poor functional capacity We have been able to identify the Profiles and we have seen the difference in survival Drop in stroke rate? Gender differences Drop in infection rates

Do we have equipoise? Pumps are smaller  Surgery less invasive Continuous flow pumps—better survival  Pumps more durable Improvements in HRQoL

Figure 4 Comparisons for mechanical circulatory support patients with complete data on the EQ-5D according to Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles: (A) visual analog scale; (B) mobility, any problems; (C)... Kathleen L. Grady, David Naftel, Lynne Stevenson, Mary Amanda Dew, Gerdi Weidner, Francis D. Pagani, James K... The Journal of Heart and Lung Transplantation, Volume 33, Issue 4, 2014,

Improvements in Functional Capacity Rogers J et al. JACC Vol. 55, No. 17, 2010

Improvements in line infection

Do we have equipoise? Profiles are truly descriptive and discriminatory Barge-Caballero E et al. Circ Heart Fail. 2013;6:

Figure 4 Actuarial survival post-LVAD. Andrew J. Boyle, Deborah D. Ascheim, Mark J. Russo, Robert L. Kormos, Ranjit John, Yoshifumi Naka, Annetine... Clinical outcomes for continuous-flow left ventricular assist device patients stratified by pre-operative INTERMACS classification The Journal of Heart and Lung Transplantation, Volume 30, Issue 4, 2011, Grp 1= Profile 1 Grp 2= Profile 2,3, Grp 3= Profile 4-7

Who are we implanting MCS? We are already implanting on the less sick

BUT Who are the patients? Age? When to intervene? NYHA Imprecise Nature and the “eye of the beholder”

A depiction of the clinical course of heart failure with associated types and intensities of available therapies. Allen L et al. Circulation 2012;125: Copyright © American Heart Association, Inc. All rights reserved.

All-Cause Mortality (NYHA Class II-III) HR 0.93 (95% CI 0.84, 1.02, P=0.13) HR 0.96 (95% CI: 0.79, 1.17), P = Excellent medical/device therapy

Teuteberg JJ. J Am Coll Cardiol 2012;60:44–51)

P.C. Patel, G.C. Stewart, M.M. Kittleson, J.A. Cowger, C.B. Patel, M.M. Mountis, F.L. Johnson, J.E. Rame Patients with INTERMACS 4-7 Heart Failure Have Reduced Quality of Life The Journal of Heart and Lung Transplantation, Volume 31, Issue 4, Supplement, 2012, S62 - S63

Figure 2 Physical function/activities of daily living dimensions on the EQ-5D according to Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles: (A) mobility problems; (B) unusual activities problems; and (C) self-care pr... Kathleen L. Grady, David Naftel, Lynne Stevenson, Mary Amanda Dew, Gerdi Weidner, Francis D. Pagani, James K... The Journal of Heart and Lung Transplantation, Volume 33, Issue 4, 2014,

Adult Primary Continuous Flow LVAD/BiVADs, n=6732 By Age Groups Months post implant Event: Death (censored at transplant and recovery) % Survival Grp 1: < 50 yrs, n= 1758 Deaths=293 INTERMACS: June 2006 – December 2012: CMS Report Grp 2: 50–64 yrs, n= 3054 Deaths=648 Grp 3: yrs, n= 1030 Deaths= 275 Overall p < Grp 4: 70+ yrs, n= 889 Deaths= 268 Figure 3 INTERMACS 4/21/2013

Figure 21 Freedom from adverse events listed in Figure 19, stratified by Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level. Error bars indicate±1 standard error. BIVAD, biventr... James K. Kirklin, David C. Naftel, Robert L. Kormos, Lynne W. Stevenson, Francis D. Pagani, Marissa A. Miller... Fifth INTERMACS annual report: Risk factor analysis from more than 6,000 mechanical circulatory support patients The Journal of Heart and Lung Transplantation, Volume 32, Issue 2, 2013,

Figure 1 Time of cumulative hospital participation and patients entered into the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database.... Kirklin et al. The Journal of Heart and Lung Transplantation, Volume 32, Issue 2, 2013, Boyle AJ et al. JACC, Volume 63, Issue 9, 2014, Figure 2 Impact of Age and Sex on Post-Discharge Bleeding, Hemorrhagic Stroke, Ischemic Stroke, and Pump Thrombosis Event rates for men are shown in gray, and rates for women are shown in black. Unacceptable risks for the less sick?

THANK YOU!

Preoperative INTERMACS Profiles Determine Postoperative Outcomes in Critically Ill Patients Undergoing Emergency Heart TransplantationClinical Perspective by Eduardo Barge-Caballero, Javier Segovia-Cubero, Luis Almenar-Bonet, Francisco Gonzalez-Vilchez, Adolfo Villa-Arranz, Juan Delgado-Jimenez, Ernesto Lage-Galle, Felix Perez-Villa, Jose L. Lambert-Rodríguez, Nicolas Manito-Lorite, Jose M. Arizon- Del Prado, Vicens Brossa-Loidi, Domingo Pascual-Figal, Luis De la Fuente-Galan, Marisa Sanz-Julve, Javier Muñiz-Garcia, and Marisa Crespo-Leiro Circ Heart Fail Volume 6(4): July 16, 2013 Copyright © American Heart Association, Inc. All rights reserved.

Causes of death pertaining to preoperative Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles. Barge-Caballero E et al. Circ Heart Fail. 2013;6: Copyright © American Heart Association, Inc. All rights reserved.

Distribution of patients during the study period. Barge-Caballero E et al. Circ Heart Fail. 2013;6: Copyright © American Heart Association, Inc. All rights reserved.

Figure 1 EQ-5D visual analog scale (VAS) results according to according to Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles. The range bars indicate the standard error. Kathleen L. Grady, David Naftel, Lynne Stevenson, Mary Amanda Dew, Gerdi Weidner, Francis D. Pagani, James K... The Journal of Heart and Lung Transplantation, Volume 33, Issue 4, 2014,

INTERMACS profile (5) NA (42) (29) (24) Jorde UP et al. (J Am Coll Cardiol 2014;63:1751–7)

In-hospital postoperative outcomes after emergency heart transplantation. Barge-Caballero E et al. Circ Heart Fail. 2013;6: Copyright © American Heart Association, Inc. All rights reserved.

Long-term survival after heart transplantation. Barge-Caballero E et al. Circ Heart Fail. 2013;6: Copyright © American Heart Association, Inc. All rights reserved.