Clinical InvestigationsAdvanced heart failure patients supported with ambulatory inotropic therapy: What defines success of therapy?
Introduction
As a result of improvements in medical and surgical therapy for heart failure (HF), a growing number of patients are living with end-stage disease. As a result, the demand for advanced therapies such as heart transplant (HT) and left ventricular assist device (LVAD) continues to increase. In step with this, inotropic infusion is increasingly used as a short-term therapy for in-hospital stabilization of cardiogenic shock or less severe decompensation, and ambulatory inotropic therapy (AIT) has broad use in palliative care and/or as a bridge to surgical therapies for advanced heart failure.1,2 From 2010-2014 alone, Medicare data suggests a marked increase in the use of AIT, with spending that totaled nearly $250 million.3 For hospitalized patients who are deemed “inotrope-dependent,” AIT offers the opportunity for patients to go home - to consider or prepare for HT or LVAD - or to accept AIT as part of a palliative care plan or try for slow cross-titration to oral guideline-directed heart failure medications. AIT also aligns patient preference to go home with a hospital goal of decreased length of stay.
The American College of Cardiology/American Heart Association (ACC/AHA) assigns a Class IIa recommendation to AIT as Bridge to Transplant (BTT), and a Class IIb for palliative care.4 Critical to assessing the safety and efficacy of AIT is understanding whether the goal of AIT was achieved and if so, at what cost with regard to type and frequency of complications and unintended consequences. In the contemporary era, there remain insufficient data describing outcomes of AIT, specifically with regard to intention-to-treat outcomes, rates of rehospitalization and complications of therapy. Furthermore, in the era of mechanical circulatory support, few studies have examined the safety and efficacy of AIT as bridge to HT, specifically to avoid the “LVAD step” as bridge to transplant.
Thus, the objectives of the current study were to (1) describe the experience of AIT at a large volume, tertiary care heart failure center, (2) assess overall survival of patients on AIT, (3) assess intention-to-treat outcomes of AIT as bridge to advanced therapies and as palliation, with a specific focus on HT candidates, and (4) describe complications associated with AIT such as rates of rehospitalization, ventricular arrhythmias and indwelling line infections.
Section snippets
Study design
We retrospectively reviewed all adult patients who were discharged with AIT from Columbia University Irving Medical Center between January 1, 2011 to July 1, 2017. Patients were excluded from the analysis if they had previously received an LVAD or HT, had a primary diagnosis of pulmonary arterial hypertension or if they were discharged to follow-up at another institution. Patients were categorized into groups by intent of therapy; bridge to transplant (BTT), bridge to LVAD (BTVAD) or as part of
Patient population
Between January 1, 2011 and July 1, 2017, 241 patients discharged on AIT and who met inclusion criteria for this retrospective, observational analysis were included (Figure 1). Among these, 81 patients were on AIT as BTT (approved by the Heart Transplant Committee and formally listed for HT), 70 patients as BTVAD (approved by the LVAD Committee) and 49 patients were on AIT as part of a palliative care plan. Our institutional practice is to recommend LVAD implant in patients who are
Discussion
The current study describes a large volume, single center experience with AIT in the contemporary era. The salient findings of the current study include: 1) only 42% of the BTT cohort received HT within 18 months of follow-up, and there was a 14.8% rate of death or delisting for too sick during this time 2) patients in the BTVAD where delay to LVAD was 49+-79 days, at time of LVAD surgery 61.7% underwent LVAD as INTERMACS 1-2 with 1-year post LVAD survival of 90% 3) only 24.5% of patients in
Conclusions
Overall outcomes of AIT appear to have improved in the contemporary era. AIT appeared to be a feasible strategy to delay LVAD implantation in destination therapy candidates for a short period of time, perhaps just long enough to get one's “affairs in order.”17 However, BTT AIT does not ameliorate the risk of clinical decompensation requiring more urgent LVAD implantation and increasing the risk of death or delisting. Thus, these risks must be weighed against patient preferences in the context
Funding
None
Disclosures
The authors have no disclosures.
Acknowledgments
None
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