Cognitive Improvement Post-Placement of Left Ventricular Assist Device

Abstract

Mechanical assist devices have emerged as an established therapeutic option for patients with end-stage heart failure. Recognizing patients who will do poorly postimplant is essential to optimize patient management and outcomes. Hypothesis: Since albumin level may reflect nutritional status, improvement in albumin from pre to postimplant may be an important prognostic indicator in patients treated with continuous flow left ventricular assist devices (cfLVAD). Methods: In this retrospective single center study we included all patients who underwent cfLVAD implantation (HeartMate II and HeartWare HVAD) at an academic center from 2008 to 2014. We excluded patients who died, were transplanted, or hospitalized during the first 3 months post-implant. Pre-implant albumin was defined as the albumin closest to but prior to the day of implant and not more than 30 days before surgery. Hypoalbuminemia was defined as <3.5 g/dL and normal albumin as ≥3.5 g/dL. We tested for association with clinical outcomes post cfLVAD including 1 and 2-year survival and time to first post-implant hospitalization. Results: From 202 total patients (80% male, mean age 56 ± 16 years), 145 were included for survival analysis and 93 were included for hospitalization analysis. The mean albumin at pre-implant, 3-months post-implant and 6-months post-implant was 3.5 ± 0.6 g/ dL, 3.6 ± 0.7 g/dL, and 3.9 ± 0.5 g/dL, respectively (P < .01). Hypoalbuminemia at 3-months post-implant correlated with increased mortality (HR 2.19 CI 1.20-4.01, P = .01) and reduced time to first post-implant hospital admission (HR 2.36 CI 1.37-4.06, P < .01). Decrease in albumin from pre-implant to 3-months post-implant was also associated with increased mortality (HR 2.93 CI 1.57-5.44, P < .01) and shorter time to first postimplant hospital admission (HR 1.70 CI 1.03-2.81, P = .04). Subgroup analysis revealed that those who started with hypoalbuminemia but had normal albumin values at 3-months post-implant had improved survival and longer time to first post-implant hospitalization than those who had persistent hypoalbuminemia, decrease in albumin over time and even those who maintained normal albumin throughout. Conclusions: Our study is the first to demonstrate the importance of post-implant albumin as well as the changes in albumin from pre-to post-implant on the prognosis of cfLVAD patients. This suggests that regardless of pre-implant albumin, therapeutic intervention to improve albumin or nutritional status post-implant may prevent hospitalizations and improve outcomes.Background: Either as bridge to transplant or destination therapy, left ventricular assist devices (LVADs) serve many patients with advanced heart failure (AHF). Systemic dysfunction, including extended periods of cerebral hypoperfusion, places patients with AHF at increased risk for cognitive decline. Despite reports of improvement in multiple body systems following LVAD placement, including increased cerebral perfusion, research examining longitudinal outcomes of cognition is sparse. In prior research (...