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Kittleson MM, Ambardekar AV, Stevenson LW, Gilotra NA, Shah P, Ewald GA, Thibodeau JT, Stehlik J, Palardy M, Estep JD, Cascino TM, Baldwin JT, Jeffries N, Khalatbari S, Yosef M, Peters WT, Richards B, Mann DL, Aaronson KD, Stewart GC. An early relook identifies high-risk trajectories in ambulatory advanced heart failure. J Heart Lung Transplant 2022; 41:104-112. [PMID: 34629234 PMCID: PMC8742755 DOI: 10.1016/j.healun.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/07/2021] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Patients with ambulatory advanced heart failure (HF) are increasingly considered for durable mechanical circulatory support (MCS) and heart transplantation and their effective triage requires careful assessment of the clinical trajectory. METHODS REVIVAL, a prospective, observational study, enrolled 400 ambulatory advanced HF patients from 21 MCS/transplant centers in 2015-2016. Study design included a clinical re-assessment of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile within 120 days after enrollment. The prognostic impact of a worsening INTERMACS Profile assigned by the treating physician was assessed at 1 year after the Early Relook. RESULTS Early Relook was done in 325 of 400 patients (81%), of whom 24% had a worsened INTERMACS Profile, associated with longer HF history and worse baseline INTERMACS profile, but no difference in baseline LVEF (median 0.20), 6-minute walk, quality of life, or other baseline parameters. Early worsening predicted higher rate of the combined primary endpoint of death, urgent MCS, or urgent transplant by 1 year after Early Relook, (28% vs 15%), with hazard ratio 2.2 (95% CI 1.2- 3.8; p = .006) even after adjusting for baseline INTERMACS Profile and Seattle HF Model score. Deterioration to urgent MCS occurred in 14% vs 5% (p = .006) during the year after Early Relook. CONCLUSIONS Early Relook identifies worsening of INTERMACS Profile in a significant population of ambulatory advanced HF, who had worse outcomes over the subsequent year. Early reassessment of ambulatory advanced HF patients should be performed to better define the trajectory of illness and inform triage to advanced therapies.
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Affiliation(s)
| | | | - Lynne W. Stevenson
- Section of Advanced Heart Failure and Transplant Cardiology, Division of Cardiovascular Medicine, Vanderbilt University Medical Center Nashville, TN
| | - Nisha A. Gilotra
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Palak Shah
- Heart Failure & Transplantation, Inova Heart and Vascular Institute, Falls Church, VA
| | - Gregory A. Ewald
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, St Louis, MO
| | - Jennifer T. Thibodeau
- Division of Cardiology, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah Health, University of Utah School of Medicine, Salt Lake City, UT
| | - Maryse Palardy
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
| | - Jerry D. Estep
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Thomas M. Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
| | | | - Neal Jeffries
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD
| | - Shokoufeh Khalatbari
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI
| | - Matheos Yosef
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI
| | - Wendy Taddei Peters
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Blair Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, MI
| | - Douglas L. Mann
- Department of Medicine, Division of Cardiology, Washington University School of Medicine, St Louis, MO
| | - Keith D. Aaronson
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI
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Abstract
PURPOSE OF REVIEW Improving outcomes with durable mechanical circulatory support have led to expanding interest in the earlier recognition of patients destined to develop refractory heart failure (HF). The recognition of advanced HF has received increasing attention. RECENT FINDINGS The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry developed patient profiles of advanced HF to describe the spectrum of patients with refractory HF undergoing mechanical circulatory support. These patient profiles have been extended to advanced HF patients on medical therapy and used to align outcomes with medical and device therapy in the Medical Arm of Mechanically Assisted Circulatory Support (MedaMACS) registries and the ROADMAP study. Shared decision-making about treatment options for advanced HF requires individualized consideration of risks and benefits beyond survival. Future studies, including the ongoing Registry for Vital Information for VADs in Ambulatory Life (REVIVAL) study, will provide prognostic information for patients transitioning from stage C to stage D HF to help patients, caregivers, and physicians navigate the increasingly complex terrain of HF care.
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Ambardekar AV, Kittleson MM, Palardy M, Mountis MM, Forde-McLean RC, DeVore AD, Pamboukian SV, Thibodeau JT, Teuteberg JJ, Cadaret L, Xie R, Taddei-Peters W, Naftel DC, Kirklin JK, Stevenson LW, Stewart GC. Outcomes with ambulatory advanced heart failure from the Medical Arm of Mechanically Assisted Circulatory Support (MedaMACS) Registry. J Heart Lung Transplant 2018; 38:408-417. [PMID: 30948210 DOI: 10.1016/j.healun.2018.09.021] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/04/2018] [Accepted: 09/25/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The outlook for ambulatory patients with advanced heart failure (HF) and the appropriate timing for left ventricular assist device (LVAD) or transplant remain uncertain. The aim of this study was to better understand disease trajectory and rates of progression to subsequent LVAD therapy and transplant in ambulatory advanced HF. METHODS Patients with advanced HF who were New York Heart Association (NYHA) Class III or IV and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Profiles 4 to 7, despite optimal medical therapy (without inotropic therapy), were enrolled across 11 centers and followed for the end-points of survival, transplantation, LVAD placement, and health-related quality of life. A secondary intention-to-treat survival analysis compared outcomes for MedaMACS patients with a matched group of Profile 4 to 7 patients with LVADs from the INTERMACS registry. RESULTS Between May 2013 and October 2015, 161 patients were enrolled with INTERMACS Profiles 4 (12%), 5 (32%), 6 (49%), and 7 (7%). By 2 years after enrollment, 75 (47%) patients had reached a primary end-point with 39 (24%) deaths, 17 (11%) undergoing LVAD implantation, and 19 (12%) receiving a transplant. Compared with 1,753 patients with Profiles 4 to 7 receiving LVAD therapy, there was no overall difference in intention-to-treat survival between medical and LVAD therapy, but survival with LVAD therapy was superior to medical therapy among Profile 4 and 5 patients (p = 0.0092). Baseline health-related quality of life was lower among patients receiving a LVAD than those enrolled on continuing oral medical therapy, but increased after 1 year for survivors in both cohorts. CONCLUSIONS Ambulatory patients with advanced HF are at high risk for poor outcomes, with only 53% alive on medical therapy after 2 years of follow-up. Survival was similar for medical and LVAD therapy in the overall cohort, which included the lower severity Profiles 6 and 7, but survival was better with LVAD therapy among patients in Profiles 4 and 5. Given the poor outcomes in this group of advanced HF patients, timely consideration of transplant and LVAD is of critical importance.
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Affiliation(s)
- Amrut V Ambardekar
- Department of Medicine, Division of Cardiology, University of Colorado, Aurora, Colorado, USA.
| | - Michelle M Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Maryse Palardy
- Department of Internal Medicine/Cardiovascular, University of Michigan, Ann Arbor, Michigan, USA
| | - Maria M Mountis
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Adam D DeVore
- Division of Cardiology and Duke Clinical Research Institute, Duke University Medical School, Durham, North Carolina, USA
| | - Salpy V Pamboukian
- Division of Cardiovascular Sciences, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jennifer T Thibodeau
- Department of Internal Medicine/Cardiology, University of Texas Southwestern, Dallas, Texas, USA
| | - Jeffrey J Teuteberg
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University, Stanford, California, USA
| | - Linda Cadaret
- Department of Internal Medicine, Division of Cardiology, University of Iowa, Iowa City, Iowa, USA
| | - Rongbing Xie
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Wendy Taddei-Peters
- Division of Cardiovascular Diseases, Advanced Technologies and Surgery Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - David C Naftel
- Department of Internal Medicine, Division of Cardiology, University of Iowa, Iowa City, Iowa, USA
| | - James K Kirklin
- Department of Internal Medicine, Division of Cardiology, University of Iowa, Iowa City, Iowa, USA
| | - Lynne W Stevenson
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Garrick C Stewart
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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