Effect of Diabetes on Short- and Long-term Outcomes After Left Ventricular Assist Device Implantation

Impact of Diabetes Mellitus on Outcomes in Patients with Left Ventricular Assist Devices

Heart failure (HF) represents a significant health burden in the United States, resulting in substantial mortality and healthcare costs. Through the array of treatment options available, including lifestyle modifications, medications, and implantable devices, HF management has evolved. Left ventricular assist devices (LVADs) have emerged as a crucial intervention, particularly in patients with advanced HF. However, the prevalence of comorbidities such as diabetes mellitus (DM) complicates treatment outcomes. By elucidating the impact of DM on LVAD outcomes, this review aims to inform clinical practice and enhance patient care strategies for individuals undergoing LVAD therapy. Patients with DM have higher rates of hypertension, dyslipidemia, peripheral vascular disease, and renal dysfunction, posing challenges to LVAD management. The macro/microvascular changes that occur in DM can lead to cardiomyopathy and HF. Glycemic control post LVAD implantation is a critical factor affecting patient outcomes. The recent literature has shown significant decreases in hemoglobin A1c following LVAD implantation, representing a possible bidirectional relationship between DM and LVADs; however, the clinical significance of this decrease is unclear. Furthermore, while some studies show increased short- and long-term mortality in patients with DM after LVAD implantation, there still is no literature consensus regarding either mortality or major adverse outcomes in DM patients.

Effect of Diabetes Mellitus on Outcomes in Patients With Left Ventricular Assist Device - Analysis of Data From a Japanese National Database

BACKGROUND

The objective of this study is to investigate the effect of preoperative diabetes on all-cause mortality and major postoperative complications among patients with continuous-flow left ventricular assist device (LVAD) by using data from a national database.Methods and Results: The 545 study patients who underwent primary HeartMateII implantation between 2013 and 2019 were divided into 2 groups according to their diabetes mellitus (DM) status; patients with DM (n=116) and patients without DM (n=429). First, the on-device survival and incidence of adverse events were evaluated. Second, after adjusting for patients' backgrounds, the change of laboratory data in the 2 groups were compared. Overall, on-device survival at 1, 2, and 3 years was almost equivalent between the 2 groups; it was 95%, 94%, and 91% in patients without DM, and 93%, 91%m and 91% in patients with DM (P=0.468) The incidence of adverse events was similar between 2 groups of patients, except for driveline exit site infection in the adjusted cohort. Cox proportional hazards regression analysis revealed younger age (HR: 0.98 (95% confidence interval (CI): 0.97-0.99, P=0.001) and presence of DM (HR: 1.83 (95% CI: 1.14-2.88), P=0.016) as significant predictors of driveline infection. Laboratory findings revealed no differences between groups throughout the periods.

CONCLUSIONS

The clinical results after LVAD implantation in DM patients were comparable with those in non-DM patients, except for the driveline exit site infection.

The impact of diabetes on short-, intermediate- and long-term mortality following left ventricular assist device implantation

OBJECTIVES

Type 2 diabetes mellitus (DM) is a frequent comorbidity among patients suffering from advanced heart failure necessitating a left ventricular assist device (LVAD) implant. The goal of this study was to evaluate the impact of type 2 DM on early and long-term outcomes of patients following an LVAD implant.

METHODS

We performed an observational cohort study in a large tertiary care centre in Israel. All data of patients who underwent a continuous flow LVAD implant between 2006 and 2020 were extracted from our departmental database. Patients were divided into 2 groups: group I (patients without diabetes) and group II (patients with diabetes). We compared short-term (30-day and 3-month) mortality, intermediate-term (1- and 3-year) mortality and long-term (5 year) mortality between the 2 groups.

RESULTS

The study population included 154 patients. Group I (patients without diabetes) comprised 88 patients and group II (patients with diabetes) comprised 66 patients. The mean follow-up duration was 38.2 ± 30.3 months. Short- and intermediate-term mortality (30 days, 1 year and 3 years) was higher in the group with DM compared with the group without DM but did not reach any statistically significant difference: 16.1% vs 9.8% (P = 0.312), 24.2% vs 17.3% (P = 0.399) and 30.6% vs 21.9% (P = 0.127) respectively. Long-term 5-year mortality was significantly higher in the group with DM compared to the group without: 38.7% vs 24.4% (P = 0.038). Furthermore, predictors of long-term mortality included diabetes (hazard ratio 2.09, confidence interval 1.34-2.84, P = 0.004), as demonstrated by regression analysis.

CONCLUSIONS

Patients with diabetes and those without diabetes have similar 30-day and short- and intermediate-term mortality rates. The mortality risk of diabetic patients begins to increase 3 years after an LVAD implant. Diabetes is an independent predictor of long-term, 5-year mortality after an LVAD implant.

CLINICAL TRIAL REGISTRATION

Ethical Committee of Sheba Medical Centre, Israel, on 2 December 2014, Protocol 4257.

The Impact of Left Ventricular Assist Device Infections on Postcardiac Transplant Outcomes: A Systematic Review and Meta-Analysis

Left ventricular assist devices (LVADs) are associated with numerous short- and long-term complications, including infection. The impact LVAD infections have on clinical outcomes after transplantation is not well established. We sought to determine whether the presence of infection while on LVAD support negatively influences outcomes after cardiac transplantation. We searched electronic databases and bibliographies for full text studies that identified LVAD infections during support and also reported on posttransplant outcomes. A meta-analysis of posttransplant survival was conducted using a random effects model. Of 2,373 records, 13 bridge to transplant (BTT) cohort studies were selected (n = 6,631, 82% male, mean age 50.7 ± 2.7 years). A total of 6,067 records (91.5%) received transplant. There were 3,718 (56.1%) continuous-flow LVADs (CF-LVADs), 1,752 (26.4%) pulsatile LVADs, and 1,161 (17.5%) unknown type records. A total of 2,586 records (39.0%) developed LVAD infections. Patients with LVAD infections were younger (50.5 ± 1.5 vs. 51.3 ± 1.5, p = 0.02), had higher body mass indeices (BMIs) (28.4 ± 0.7 vs. 26.8 ± 0.4, p < 0.01), and longer LVAD support times (347.0 ± 157.6 days vs. 180.2 ± 106.0 days, p < 0.01). Meta-analysis demonstrated increased posttransplant mortality in those patients who had an LVAD infection (hazard ratio [HR] 1.30, 95% CI: 1.16-1.46, p < 0.001). Subgroup meta-analyses by continuous-flow and pulsatile device type demonstrated significant increased risk of death for both types of devices (HR 1.47, 95% CI: 1.22-1.76, p < 0.001 and 1.71, 95% CI: 1.19-2.45, p = 0.004, respectively). Patients who develop LVAD infections are younger, have higher BMIs and longer LVAD support times. Our data suggests that LVAD-related infections result in a 30% increase in postcardiac transplantation mortality. Strategies to prevent LVAD infections should be implemented to improve posttransplant outcomes in this high-risk population.

Meta-Analysis Comparing Risk for Adverse Outcomes After Left Ventricular Assist Device Implantation in Patients With Versus Without Diabetes Mellitus

Patients with diabetes mellitus (DM) are known to have reduced life expectancy and be at increased risk for multiple morbidities including serious infection. However, published data on DM outcomes after left ventricular assist device (LVAD) implantation are sparse, inconsistent and individual studies are small with limited power. We conducted a systematic review and meta-analysis to compare survival and adverse events post-LVAD in DM versus non-DM (NDM) patients. Medline, Scopus, and Cochrane Central databases were searched for studies comparing outcomes in DM and NDM patients who underwent LVAD implantation for advanced heart failure. Results were reported as random effect risk ratios (RR) with 95% confidence intervals. We identified 5 retrospective cohort studies, at low risk of bias, reporting on 1,351 patients (n = 488 DM). There was increased 30-day mortality (RR 1.57 [1.00, 2.47]; p = 0.05; I² = 0%) among DM versus NDM. The DM and NDM groups did not differ significantly in terms of 1-year mortality (RR 1.15 [0.98, 1.35]; p = 0.08; I² = 39%), device-related infection (RR 1.05 [0.92, 1.19]; p = 0.88; I² = 0%), ischemic stroke (RR 1.29 [0.91, 1.83]; p = 0.69; I² = 0%), hemorrhagic stroke (RR 1.10 [0.42, 2.83]; p = 0.85; I² = 69%), or bleeding (RR 1.06 [0.80, 1.40]; p = 0.70; I² = 27%). After LVAD implantation, patients with DM, versus patients without, have a modestly elevated 30-day mortality rate. However, 1-year mortality and morbidity did not differ.

2019 EACTS Expert Consensus on long-term mechanical circulatory support

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.

Clinical Impact of Diabetes Mellitus on Short-Term Outcomes andIn-Hospital Mortality of Cardiac Mechanical Support with Left Ventricular Assist Device (LVAD): A Retrospective Study from a National Database

BACKGROUND

Cardiac support with left ventricular assist devices (LVAD) is a growing field. LVAD are increasingly used for patients with advanced congestive heart failure. Multiple studies have evaluated the outcomes of cardiac support with LVAD in patients with and without diabetes mellitus (DM), yet we still have conflicting results. This study aimed to assess the clinical impact of diabetes mellitus on patients undergoing cardiac support with LVAD.

METHODS

Diabetic patients who underwent mechanical support with LVAD between 2011 and 2014 were identified in the National Inpatient Sample (NIS) database using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The primary outcome was the effect of diabetes mellitus on inpatient mortality. Secondary outcomes were the impact of diabetes on other immediate post-LVAD complications and the cost of hospitalization. Multivariable logistic regression models analysis was performed to address potential confounding.

RESULTS

After adjusting for patient-level and hospital-level characteristics, diabetic patients who underwent cardiac support with LVAD have no significant increase in in-hospital mortality (OR: 0.79, 95% CI (0.57-1.10), p = 0.166), post-LVAD short-term complications and cost of hospitalization (OR: 0.97, 95% CI (0.93-1.01), p = 0.102).

CONCLUSION

Cardiac mechanical support with LVAD implantation is feasible and relatively safe in patients with diabetes and stage-D heart failure as a bridge for transplantation or as destination therapy for patients who are not candidates for transplantation. However, further trials and studies using bigger study sample and more comprehensive databases, need to be conducted for a stronger and more valid evidence.

Factors Associated With Prolonged Survival in Left Ventricular Assist Device Recipients

BACKGROUND

Limited data exist on factors predicting prolonged survival in left ventricular assist device (LVAD) recipients. We sought to identify patient characteristics and complications associated with prolonged survival.

METHODS

We conducted retrospective review of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database, including primary continuous-flow LVAD recipients, between May 2012 and March 2013. Patients were identified as having survived with a device in place after 3 years or not, conditional on having initially survived 6 months. Patients who received a transplant, underwent explant due to recovery, or were lost to follow-up before 3 years were excluded. Multivariate logistic regression evaluated perioperative factors and adverse events within 6 months associated with long survival.

RESULTS

Of 1,116 patients who survived past the initial 6 months, 725 (65%) survived beyond 3 years. On univariate analysis, long-term survivors were significantly younger, were less likely to be white, supported for destination therapy, have diabetes, solid-organ cancer, or take amiodarone. On multivariate analysis, factors associated with increased odds of death at 3 years included diabetes, amiodarone use, and developing stroke, gastrointestinal bleeding, hemolysis, or pump thrombosis within 6 months of implantation.

CONCLUSIONS

Preoperative diabetes and amiodarone use were associated with poor long-term survival in LVAD recipients. Development of early complications of stroke, gastrointestinal bleeding, hemolysis, or pump thrombosis was also associated with poor long-term survival. Early diagnosis and treatment of these complications may improve survival in LVAD recipients.

Ventricular Assist Device Infections

This article reviews the diagnostic criteria for ventricular assist device (VAD) infection, pathogenesis, and microbiology as well as the diagnostic pathway when patients present with signs and symptoms concerning for VAD infection. Recommendations regarding infection prevention and management are reviewed as well.

Influence of Diabetes Mellitus on Outcomes in Patients After Left Ventricular Assist Device Implantation

BACKGROUND

Despite previous studies, the mortality risk of patients with diabetes mellitus after left ventricular assist device (LVAD) implant remains unclear. In addition, the relationship between the degree of glycemic control and long-term mortality risk in LVAD patients with diabetes has not been established.

METHODS

Ninety-five nondiabetic patients and 96 diabetic patients from the University of Rochester Medical Center who received a HeartMate II (Thoratec, Pleasanton, CA) continuous-flow LVAD between May 2008 and June 2014 were included in this study. The primary outcome was all-cause mortality. Secondary outcomes included rates of infection, neurologic dysfunction, renal dysfunction, and rehospitalization. Kaplan-Meier survival analyses and Cox models were utilized.

RESULTS

During follow-up, 32 diabetic patients (33%) and 15 nondiabetic patients (16%) died after LVAD implantation. Cumulative probability of death was higher for diabetic patients when compared with nondiabetic patients (42% versus 21% at 3 years, p = 0.013). There were no significant differences in overall rates of infection, neurologic dysfunction, and rehospitalization between the two groups. However, after an initial secondary outcome event, diabetic patients continued to have a higher mortality rate when compared with nondiabetic patients. There was no statistically significant difference in the risk of death between diabetic patients with pre-LVAD hemoglobin A1c less than 7.0% and diabetic patients with pre-LVAD hemoglobin A1c 7.0% or greater (hazard ratio 1.71, 95% confidence interval: 0.72 to 4.08, p = 0.223).

CONCLUSIONS

Diabetic patients who underwent LVAD implantation had a higher risk of death compared with nondiabetic patients. Adverse event rates did not differ between the two groups. Finally, the degree of glycemic control in diabetic patients before LVAD was not found to influence mortality.

Impact of Diabetes Mellitus on Outcomes in Patients Supported With Left Ventricular Assist Devices

Background

Diabetes mellitus (DM) is a risk factor for morbidity and mortality in patients with heart failure. The effect of DM on post–left ventricular assist device (LVAD) implantation outcomes is unclear. This study sought to investigate whether patients with DM had worse outcomes than patients without DM after LVAD implantation and whether LVAD support resulted in a better control of DM.

Methods and Results

We retrospectively reviewed 341 consecutive adults who underwent implantation of LVAD from 2007 to 2016. Patient characteristics and adverse events were studied and compared between patients with and without DM. One hundred thirty-one patients (38%) had DM. Compared with patients without DM, those with DM had higher rates of ischemic cardiomyopathy, LVAD implantation as destination therapy, and increased baseline body mass index. In a proportional hazards (Cox) model with adjustment for relevant covariates and median follow-up of 16.1 months, DM was associated with increased risk of all-cause mortality (hazard ratio, 1.73; 95% confidence interval: 1.18–2.53; P =0.005) and increased risk of nonfatal LVAD-related complications, including a composite of stroke, pump thrombosis, and device infection (hazard ratio, 2.1; 95% confidence interval: 1.35–3.18; P =0.001). Preoperative hemoglobin A1c was not significantly associated with mortality or adverse events among patients with DM. LVAD implantation resulted in a remarkable decrease in hemoglobin A1c levels (7.4±1.9 pre-LVAD versus 6.0±1.5 and 6.3±1.4 after 3 and 12 months post-LVAD, respectively; P <0.0001) and a significant reduction in requirements of DM medications.

Conclusions

DM is associated with increased rates of all-cause mortality and major adverse events despite favorable glycemic control after LVAD implantation.

Neurohormonal Regulation and Improvement in Blood Glucose Control: Reduction of Insulin Requirement in Patients with a Nonpulsatile Ventricular Assist Device

<p><b>Background:</b> Heart failure is associated with prolonged stress and inflammation characterized by elevated levels of cortisol and circulating catecholamines. Persistent sympathetic stimulation secondary to the stress of heart failure causes an induced insulin resistance, which creates a need for higher doses of insulin to adequately manage hyperglycemia in this patient population. We hypothesized that cortisol and catecholamine levels would be elevated in end-stage heart failure patients, however, would be reduced after the implantation of a left ventricular assist device (LVAD). Insulin requirements would therefore be reduced post LVAD implant and control of diabetes improved as compared with pre-implant.</p><p><b>Methods:</b> Pre- and postoperative cortisol, catecholamine, glycated hemoglobin, and blood glucose levels were evaluated retrospectively in 99 LVAD patients at a single center from January 2007 through November 2011. Serum was collected before LVAD implantation and monthly after implantation for 12 months consecutively. Results were evaluated and compared to insulin requirements, if any, before and after implant. Plasma levels were measured by ELISA.</p><p><b>Results:</b> There were a total of 99 patients (81 men and 18 women). Two patients were implanted twice due to pump dysfunction. Mean age was 59 years, � 10, with a median of 63 years. Of those patients, 64 had ischemic cardiomyopathy and 35 had dilated cardiomyopathy. The total patient years of LVAD support were 92.5 years. All patients received a continuous flow left ventricular assist device. Type II diabetes mellitus was diagnosed in 28 patients. Of those patients, 24 required daily insulin with an average dose of 45 units/day. Average preoperative glycated hemoglobin (HbA1c) levels were 6.8% with fasting blood glucose measurements of 136 mg/dL. Mean cortisol levels were measured at 24.3 ?g/dL before LVAD implantation, with mean plasma catecholamine levels of 1824 ?g/mL. Post operatively, average HbA1c levels were 5.38% with fasting blood glucose measurements of 122 mg/dL. Mean cortisol levels were measured at 10.9 ?g/dL with average plasma catecholamine levels were 815 ?g/mL. There was a significant decrease in both cortisol levels post LVAD implant (<i>P</i> = 0.012) as well as catecholamine levels (<i>P</i> = 0.044). The average insulin requirements post LVAD implant were significantly reduced to 13 units/day (<i>P</i> = 0.001). Six patients no longer required any insulin after implant.</p><p><b>Conclusion:</b> Implantation of nonpulsatile LVADs has become a viable option for the treatment of end-stage heart failure, helping to improve patient quality of life by decreasing clinical symptoms associated with poor end-organ perfusion. Frequently, diabetes is a comorbid condition that exists among heart failure patients and with the reduction of the systemic inflammatory and stress response produced by the support of a nonpulsatile LVAD, many patients may benefit from a reduction in their blood glucose levels, as well as insulin requirements.</p>

Variability in infection control measures for the percutaneous lead among programs implanting long-term ventricular assist devices in the United States

Ventricular assist devices (VADs) are a surgical treatment for heart failure. These devices may be implanted as a bridge to transplant or as destination therapy. After surgical recovery and education regarding device care, patients are discharged home. Meticulous care of the driveline must be taken to prevent infection and trauma of the site throughout the perioperative event and for the duration of support. Currently a standardized protocol for care of the driveline and exit site does not exist. VAD coordinators from across the country discussed the variability in care at different centers in the United States through a series of conference calls. A survey consisting of 16 questions was developed. The survey included questions on preoperative antibiotic recommendations, driveline placement and exit site suturing, frequency of dressing changes, and showering practices. VAD coordinators shared center-specific dressing protocols and any driveline success stories. This survey was sent to 73 centers; 38 centers (52%) responded. The purpose of the survey was to define current practice in order to move toward a standard of practice or protocol based on expert opinion for VAD driveline care and to assess the need for future studies.

Left ventricular assist device-related infections: past, present and future

Over the last decade, left ventricular assist device (LVAD) implantation has emerged as an alternative treatment strategy in patients with advanced heart failure irrespective of their transplant eligibility. However, success and applicability of this therapy is largely limited by high complication rates associated with these devices. Although superior outcomes have been achieved with the second-generation continuous-flow LVADs, device-related infections continue to be a prevalent complication in this patient population and contribute significantly to the financial burden of this therapy due to an increased need for hospitalizations and surgical interventions. Patient selection, device design and LVAD-induced immune system dysfunction appear to be major risk factors for the development of device-related infections. Improvements in device design and better patient selection strategies, particularly with respect to identifying individuals with genetic susceptibility to device-related infections, may further reduce this prevalent complication and improve outcomes in patients with advanced heart failure.