2018 Outcomes & Quality Report in Cardiovascular Services

Advanced Heart Failure

 

Noteworthy Progress in Heartmate 3™

On August 28, 2018, the FDA approved the HeartMate 3™ left ventricular assist device (LVAD) as a destination therapy for patients with advanced heart failure who are not eligible for transplant, as a life-long implant. The HeartMate 3™ LVAD was approved as bridge to transplant and as a bridge to myocardial recovery in a preceding year. FDA approval was supported by the landmark MOMENTUM 3 Trial — the largest randomized trial in the history of mechanical circulatory support — which included >1,000 patients. New York-Presbyterian/Columbia surgeons and cardiologists were at the forefront of this innovation: They were among the first to offer patients access to HeartMate 3™ nationwide, enrolled the largest number of patients (>6 percent of the entire enrollment), and commemorated entry of the 100th patient into the trial.

The device is available to patients at both NewYork-Presbyterian/Columbia and NewYork-Presbyterian/Weill Cornell.

The HeartMate 3™, a fully magnetically levitated centrifugal continuous-flow pump, markedly reduced complications over its predecessors, including:

• lowest published stroke rate (3-fold reduction ≥6 month post implant)

• eliminated pump thrombosis, one of the major complications of device therapy

Overall, LVAD therapy has now reached unprecedented success, as evidenced by:

• survival of 83 percent at two years, which is now comparable to heart transplantation

• increased exercise capacity — doubled six-minute walk distance (from 154 to 308 meters)

• improved quality of life based on the patient responses to Kansas City Cardiomyopathy and European Quality of Life Questionnaires

Adult ECMO

---

NewYork-Presbyterian Heart Transplant Program in the Era of the New Organ Allocation System

This past year also brought significant changes to the National Heart Allocation Policy, which now allows for 500 mile broader sharing of organs for the sickest patients and earlier access to transplant for specialized patient populations, including adult patients with congenital heart disease (CHD) and hypertrophic cardiomyopathy. NewYork-Presbyterian/Columbia physician leadership took on a national role in this policy development and implementation, which has already shown to increase heart transplantation opportunities in New York State.

Other program highlights include:

• growth in our multi-organ transplant program, including heart-kidney and heart-liver transplantation, the latter also for patients with mutational TTR amyloidosis and for adult CHD patients with Fontan-associated liver disease

• a new program for the use of hepatitis C viremic donors to increase heart transplantation opportunities for those patients with longer waiting time on the list; a course of anti-viral therapy is administered at 12 weeks after transplant to cure the transmitted hepatitis C virus

• initiation of a protocol to offer novel immunosuppressive treatment with Belatacept to desensitize patients and thereby increase their heart transplantation opportunities

Ventricular Assist Device Implants

---

NewYork-Presbyterian has performed 2,561 heart transplants between January 1988 and June 2018 — the largest volume in New York State — and maintains the largest waiting list in the state.

Adult Heart Transplant

---

Advanced Heart Failure

---

Heart Failure with Preserved Ejection Fraction

Researchers in the Greenberg Division of Cardiology at Weill Cornell undertook a study using the National Inpatient Sample to better characterize differences in management and in-hospital outcomes of atrial fibrillation among patients with heart failure with preserved ejection fraction (HFpEF) and those with heart failure with reduced ejection fraction (HFrEF). They found that the prevalence and adverse impact of atrial fibrillation on those with HFpEF was substantial, providing a rationale to rigorously investigate strategies, such as rhythm control, to improve outcomes for this vulnerable subpopulation.

Weill Cornell recently started a dedicated HFpEF program, which combines expertise in heart failure and geriatric cardiology. In addition to providing state-of-the-art clinical care, the HFpEF program also serves as a platform for several ongoing research studies sponsored by both the NIH and industry. This research is focused on multiple domains, including PH-HFpEF through our NIH PVDOMICS study and clinical trials; geriatric cardiology through a growing registry that characterizes the functional and cognitive impairments observed in HFpEF; and precision medicine through a collaboration with the Englander Institute for Precision Medicine at Weill Cornell.

Contending with Cardiogenic Shock

Columbia faculty have developed a novel minimally invasive surgical approach that combines extracorporeal membrane oxygenation (ECMO) and the external temporary ventricular assist device (Ec-VAD) for cardiogenic shock as a shortterm circulatory support. Comparing the outcomes to conventional external biventricular assist device support, patients who received Ec-VAD required fewer transfusions, had a significantly lower incidence of major bleeding events during support, and a greater percent survived to the next destination and had better overall one-year survival rates.

In a review of 124 patients who received ECMO or short-term surgical VAD following acute myocardial infarction, researchers at Columbia found that of the 55.6 percent who survived to discharge, 37.7 percent required heart replacement therapy and 62.3 percent were discharged without heart replacement therapy. Age and cardiac index at the time of implantation were predictors of survival to discharge. In another study to determine predictors of survival for patients with acute decompensated heart failure requiring venoarterial ECMO, Columbia researchers found that markers of chronic disease were powerful predictors of outcomes, while markers of clinical acuity, including hemodynamics, vasopressor/inotrope use, and lactate are not. The vast majority of survivors required durable left ventricular assist devices.