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451 Declining incidence of cardiac allograft vasculopathy: A serial angiographic review
S225
Abstracts
Adrenaline challenge provoked diagnostic abnormalities in 21% of patients, and borderline findings in 16%. The data support a significant role for adrenaline challenge in the workup of suspected familial sudden death syndromes, although precise sensitivity and specificity needs to be established. Heart and Stroke Foundation, Boston Scientific CONCLUSION:
448 SUDDEN CARDIAC DEATH AND SUPRAVENTRICULAR TACHYCARDIA INCIDENCE IN PATIENTS WITH ASYMPTOMATIC WOLFF-PARKINSON-WHITE A META-ANALYSIS
evidence of heterogeneity (P ⬍ 0.0001, I2 85.3%). Using a random effects model, the overall risk of SVT was 18 (95% CI, 11 to 26) events per 1,000 PYrs of follow-up. CONCLUSIONS: The risk of SVT is low and SCD exceedingly rare. Canadian Cardiovascular Society (CCS) CCS268 Oral CLINICAL ISSUES IN TRANSPLANTATION Monday, October 24, 2011
MN Obeyesekere, D Massel, GJ Klein, LJ Gula, AD Krahn, AC Skanes, R Yee, P Leong-Sit
451 DECLINING INCIDENCE OF CARDIAC ALLOGRAFT VASCULOPATHY: A SERIAL ANGIOGRAPHIC REVIEW
London, Ontario
R Khan, K Morant, P Pflugfelder, W Kostuk
BACKGROUND: The incidence of sudden cardiac death (SCD) and the management of this risk in patients with asymptomatic pre-excitation remains controversial. The purpose of this metaanalysis was to define the incidence of SCD/aborted SCD and supraventricular tachycardia (SVT) in patients with asymptomatic Wolff-Parkinson-White ECG pattern. METHODS: We performed a systematic search of prospective or retrospective, randomized or cohort, English-language studies in EMBASE and Medline through to February 2011. Criteria for inclusion were studies including asymptomatic patients with pre-excitation who did not undergo ablation. When studies also reported on symptomatic patients and/or catheter ablation of asymptomatic patients, only asymptomatic patients who did not undergo catheter ablation were included in the pooled analysis. For each study, incidence of SCD/aborted SCD and incidence of SVT were extracted and pooled using both a random-effects (DerSimonian-Laird) model and fixed effects model to construct 95% confidence intervals (CI). Heterogeneity analyses were performed. RESULTS: Twenty-one studies involving 12,096 person-years (PYrs) of follow-up met our inclusion criteria. Participants were primarily male (weighted average 67%) and young with mean ages in the studies ranging from 7 to 43 years. The weighted mean age was 26.5 years. Follow-up ranged from a mean of 15 months to 21.8 years. 13 SCD episodes were reported in 4,283 PYrs of follow-up in 7 studies. Rates of SCD ranged from 0.7 per 1,000 PYs to 8 per 1,000 PYrs. No events were seen in 14 studies with a total follow-up of 7,813 PYrs. Considering all patients the unadjusted rate was 1.1 SCD events per 1,000 PYrs. We found moderate evidence of statistical heterogeneity (P ⫽ 0.064, I2 34.2%). Using a fixed effects model the SCD risk was estimated at 1.0 (95% CI, 0.5 to 1.7) per 1,000 PYrs. Using a random effects model the risk of SCD is estimated at 1.6 (95% CI, 0.7 to 2.6) per 1,000 PYrs. With 95% confidence the risk of SCD was ⬍3 per 1,000 PYrs of follow-up. The development of SVT was described as an outcome in 19 studies involving 10,258 PYrs. In total there were 176 patients who developed SVT events. Rates in individual studies varied from 0 to 50 events per 1,000 PYrs. There was no statistical
London, Ontario
Coronary artery disease in the transplanted heart (cardiac allograft vasculopathy; CAV) develops insidiously and is the principle cause of death beyond 1 year of transplantation. The process is most likely immunologically mediated but may be potentiated by non-immunologic factors. We have previously shown a time dependent increasing prevalence of CAV such that by ⬎10 years ⬃60% of coronary angiograms demonstrate abnormalities (1/2 of those moderate to severe; ISHLT grades 2 or 3). To determine whether contemporary management practices post transplantation have resulted in improved early CAV outcomes, a large consecutive series of post transplant angiograms was reviewed. METHODS/RESULTS: Between April 1981 and December 2010, all available serial angiograms on patients surviving at least one year were reviewed. In total, one year data from 264 patients and 3 year data from 228 patients were available. Patients in the time period 20002010 were compared to those before 2000. In the 2000-2010 time period mycophenolate mofetil was adopted for routine use, tacrolimus largely supplanted the use of cyclosporine, and aggressive lipid lowering regimens with statins were also routinely employed. At the same time, donor age increased (29.2 ⫾ 11.6 vs 35.9 ⫾ 13.8 years, P ⬍ 0.0001), recipient age increased (46.3 ⫾ 11.9 vs 51.4 ⫾ 10.2 years, P ⬍ 0.0008) and total ischemic time increased (215.5 ⫾ 84.4 vs 240.6 ⫾ 86.1 minutes, P ⬍ 0.01). Nevertheless the incidence of angiographic CAV (any severity) has declined: 10.7% vs 6.4% ( P ⫽ 0.36) at one year and 24.3% vs 7.0% (P ⬍ 0.01) at 3 years. In the contemporary cohort 1 year mean LDL cholesterol was 2.0 ⫾ 0.7 mmol/L. Importantly, excellent lipid control was maintained to 3 years: mean LDL cholesterol 1.9 ⫾ 0.8 mmol/L. CONCLUSIONS: This review has shown a significant decline in the early development of CAV over the last decade. Refinements in post transplant management may be an important factor for this change and merit further study. The observations also support the notion that interventions which significantly modify the course of CAV can potentially be detected by coronary angiography in a small sample size over a relatively short time period. This may have implications for future studies of CAV therapies. BACKGROUND:
Abstracts
Adrenaline challenge provoked diagnostic abnormalities in 21% of patients, and borderline findings in 16%. The data support a significant role for adrenaline challenge in the workup of suspected familial sudden death syndromes, although precise sensitivity and specificity needs to be established. Heart and Stroke Foundation, Boston Scientific CONCLUSION:
448 SUDDEN CARDIAC DEATH AND SUPRAVENTRICULAR TACHYCARDIA INCIDENCE IN PATIENTS WITH ASYMPTOMATIC WOLFF-PARKINSON-WHITE A META-ANALYSIS
evidence of heterogeneity (P ⬍ 0.0001, I2 85.3%). Using a random effects model, the overall risk of SVT was 18 (95% CI, 11 to 26) events per 1,000 PYrs of follow-up. CONCLUSIONS: The risk of SVT is low and SCD exceedingly rare. Canadian Cardiovascular Society (CCS) CCS268 Oral CLINICAL ISSUES IN TRANSPLANTATION Monday, October 24, 2011
MN Obeyesekere, D Massel, GJ Klein, LJ Gula, AD Krahn, AC Skanes, R Yee, P Leong-Sit
451 DECLINING INCIDENCE OF CARDIAC ALLOGRAFT VASCULOPATHY: A SERIAL ANGIOGRAPHIC REVIEW
London, Ontario
R Khan, K Morant, P Pflugfelder, W Kostuk
BACKGROUND: The incidence of sudden cardiac death (SCD) and the management of this risk in patients with asymptomatic pre-excitation remains controversial. The purpose of this metaanalysis was to define the incidence of SCD/aborted SCD and supraventricular tachycardia (SVT) in patients with asymptomatic Wolff-Parkinson-White ECG pattern. METHODS: We performed a systematic search of prospective or retrospective, randomized or cohort, English-language studies in EMBASE and Medline through to February 2011. Criteria for inclusion were studies including asymptomatic patients with pre-excitation who did not undergo ablation. When studies also reported on symptomatic patients and/or catheter ablation of asymptomatic patients, only asymptomatic patients who did not undergo catheter ablation were included in the pooled analysis. For each study, incidence of SCD/aborted SCD and incidence of SVT were extracted and pooled using both a random-effects (DerSimonian-Laird) model and fixed effects model to construct 95% confidence intervals (CI). Heterogeneity analyses were performed. RESULTS: Twenty-one studies involving 12,096 person-years (PYrs) of follow-up met our inclusion criteria. Participants were primarily male (weighted average 67%) and young with mean ages in the studies ranging from 7 to 43 years. The weighted mean age was 26.5 years. Follow-up ranged from a mean of 15 months to 21.8 years. 13 SCD episodes were reported in 4,283 PYrs of follow-up in 7 studies. Rates of SCD ranged from 0.7 per 1,000 PYs to 8 per 1,000 PYrs. No events were seen in 14 studies with a total follow-up of 7,813 PYrs. Considering all patients the unadjusted rate was 1.1 SCD events per 1,000 PYrs. We found moderate evidence of statistical heterogeneity (P ⫽ 0.064, I2 34.2%). Using a fixed effects model the SCD risk was estimated at 1.0 (95% CI, 0.5 to 1.7) per 1,000 PYrs. Using a random effects model the risk of SCD is estimated at 1.6 (95% CI, 0.7 to 2.6) per 1,000 PYrs. With 95% confidence the risk of SCD was ⬍3 per 1,000 PYrs of follow-up. The development of SVT was described as an outcome in 19 studies involving 10,258 PYrs. In total there were 176 patients who developed SVT events. Rates in individual studies varied from 0 to 50 events per 1,000 PYrs. There was no statistical
London, Ontario
Coronary artery disease in the transplanted heart (cardiac allograft vasculopathy; CAV) develops insidiously and is the principle cause of death beyond 1 year of transplantation. The process is most likely immunologically mediated but may be potentiated by non-immunologic factors. We have previously shown a time dependent increasing prevalence of CAV such that by ⬎10 years ⬃60% of coronary angiograms demonstrate abnormalities (1/2 of those moderate to severe; ISHLT grades 2 or 3). To determine whether contemporary management practices post transplantation have resulted in improved early CAV outcomes, a large consecutive series of post transplant angiograms was reviewed. METHODS/RESULTS: Between April 1981 and December 2010, all available serial angiograms on patients surviving at least one year were reviewed. In total, one year data from 264 patients and 3 year data from 228 patients were available. Patients in the time period 20002010 were compared to those before 2000. In the 2000-2010 time period mycophenolate mofetil was adopted for routine use, tacrolimus largely supplanted the use of cyclosporine, and aggressive lipid lowering regimens with statins were also routinely employed. At the same time, donor age increased (29.2 ⫾ 11.6 vs 35.9 ⫾ 13.8 years, P ⬍ 0.0001), recipient age increased (46.3 ⫾ 11.9 vs 51.4 ⫾ 10.2 years, P ⬍ 0.0008) and total ischemic time increased (215.5 ⫾ 84.4 vs 240.6 ⫾ 86.1 minutes, P ⬍ 0.01). Nevertheless the incidence of angiographic CAV (any severity) has declined: 10.7% vs 6.4% ( P ⫽ 0.36) at one year and 24.3% vs 7.0% (P ⬍ 0.01) at 3 years. In the contemporary cohort 1 year mean LDL cholesterol was 2.0 ⫾ 0.7 mmol/L. Importantly, excellent lipid control was maintained to 3 years: mean LDL cholesterol 1.9 ⫾ 0.8 mmol/L. CONCLUSIONS: This review has shown a significant decline in the early development of CAV over the last decade. Refinements in post transplant management may be an important factor for this change and merit further study. The observations also support the notion that interventions which significantly modify the course of CAV can potentially be detected by coronary angiography in a small sample size over a relatively short time period. This may have implications for future studies of CAV therapies. BACKGROUND: