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A Peritransplant Strategy in Lung Transplant Recipients with Preformed HLA Donor-Specific Antibodies (pDSA)
S192
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
5( 13) Influence of Intraoperative Hemodynamic Factors on the Development of Acute Kidney Injury in Lung Transplantation R. Romano ,1 I. Wong,2 L. Thakuria,2 F. De Robertis,3 T. Bahrami,3 M. Amrani,3 S. Kaul,3 D. Hall,3 A. Reed,3 M. Carby,3 A. Simon,3 N. Marczin.1 1Anaesthetics, Imperial College London, London, United Kingdom; 2Imperial College London, London, United Kingdom; 3Royal Brompton and Harefield NHS Foundation Trust, Harefield, United Kingdom. Purpose: Postoperative renal dysfunction requiring renal replacement therapy occurs frequently following lung transplantation (LT) with impact on perioperative and early mortality. Beyond preoperative factors, intraoperative events may also contribute to renal problems. In search of intraoperative determinants of postoperative renal dysfunction, we have evaluated the impact of hypotension episodes (HE) and requirement for vasoactive support and usage of blood products on the development of postoperative AKI in patients undergoing bilateral sequential lung transplantation. Methods: HE lasting longer than 15 min were graded according to blood pressure targets from the electronic database record (IntelliSpace Critical Care and Anaesthesia) of 60 patients between July 2010 and April 2013 at Harefield Hospital. Vasoactive support was documented at arrival to ICU. The development of AKI was monitored during the first 3 postoperative days using AKI Network (AKIN) criteria. Results: The development of AKI was associated with more HE below the target mean arterial blood pressure of 70 mmHg (16.7 ± 8.4 vs 11.1± 3.0 p= 0.019). In addition, the frequency of HE was also related to the grading of AKI (11.1 ± 3.0; 13.0 ± 5.2; 15.0 ± 7.9 and 19.9 ± 9.5 for AKI 0, 1, 2 and 3, respectively , p= 0.013). Similarly, episodes of mean arterial blood pressure < 60 mmHg was also different between AKI and no AKI groups (5.7 ± 5.6 vs 2.1 ± 1.9, p= 0.042). HE in patients subjected to cardiopulmonary bypass was higher (16.9 ± 9.1 vs 11.5 ± 6.8 for MAP< 70 and 6.0 ± 5.6 vs 1.6 ± 1.9 for MAP< 60, p= 0.001) associated with higher incidence of grade 3 AKI (51.1% vs 7.7). Regarding vasoactive support, the use of milrinone, noradrenaline and vasopressin was higher in patients who developed AKI. AKI was also associated with higher use of blood products (5.2 vs 2.9 U for red blood cells; 2.6 vs 1.4 U for plasma and 1.3 vs 0.57 U for platelets). Conclusion: This study highlights the potential role of intraoperative factors in the development of AKI following LT. Lasting intraoperative hypotension requiring higher doses of vasoactive support, the use of cardiopulmonary bypass and increased blood transfusion appear to be associated with higher incidence and severity of AKI. These may have important implications to overall intraoperative management of LT. 5( 14) Outcome After Transplantation of Lungs Evaluated With Ex-Vivo Lung Perfusion A. Wallinder ,1 S. Ricksten,2 G.C. Riise,3 T. Nilsson,4 G. Dellgren.3 1Dep. of Cardiothoracic surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; 2Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden; 3Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; 4Cardiothoracic Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden. Purpose: Ex vivo lung perfusion (EVLP) has emerged as a reliable method for evaluation of rejected donor lungs and is now adopted by several institutions. We reviewed clinical outcome in patients transplanted with EVLP evaluated lungs at our centre and compared results to contemporary controls. Methods: Lungs deemed unsuitable for donation but with potential for improvement underwent EVLP and were transplanted if preset criteria was fulfilled. Clinical outcome was reviewed and compared to consecutive patients transplanted during the same time period with conventional donor lungs (CONV). Results: 22 donor lungs were initially rejected for Lung transplantation (Ltx) due to inferior PaO2/FiO2 ratio (n= 15), bilateral infiltrate on chest x-ray (n= 11) or on going ECMO (n= 1). Four double lungs and two single lungs were deemed unsuitable for transplantation. 18 recipients from the regular waiting list underwent either lobar (n= 1) single (n= 4) or double (n= 13) LTx with EVLP-treated lungs. Data was compared to 85 consecutive recipients of
non-EVLP lungs. Primary graft dysfunction > grade 1 at 72 hours occurred in 16% of patients in the EVLP group and 12% in the CONV group. Median ICU stay was for the EVLP group 73 hours (range, 36-936) and for CONV group51 hours (range, 19-1632), p= 0.58. There was no difference in length of hospital stay (p= 0.21). Survival, free from graft-loss, was 83% at one year in the EVLP group and 85% in the CONV group (fig. 1). Between 12 and 18 months one recipient in the EVLP group was re-transplanted and one patient transplanted with lobes died from a pulmonary embolization. At 12 months median FEV 1.0 (% of predicted) was 98% (EVLP) and 96% (CONV) for double lung recipients compared to 53% (EVLP) and 59% (CONV) for single lung recipients. Conclusion: Results after transplantation of lungs after EVLP seem noninferior to results after conventional transplantation. This finding is congruent with data from other centres. 5( 15) Is Routine Screening for Community-Acquired Respiratory Virus Infections in Lung Transplant Recipients Worthwhile? M. Greer ,1 T. Fühner,1 I. Tudorache,2 G. Warnecke,2 A. Haverich,2 T. Welte,1 J. Gottlieb.1 1Respiratory Medicine, Hanover Medical School, Hannover, Germany; 2Cardiac, Thoracic, Transplantation and Vascular Surgery, Hanover Medical School, Hannover, Germany. Purpose: Community-acquired respiratory virus (CARV) infections increase morbidity and mortality among lung transplant (LTx) recipients. Reported prevalence rates approach 9%, with detection traditionally relying on antigen testing e.g. immunofluorescence assays (IFT). Recently multiplex-PCR (mPCR) has shown better sensitivity in virus detection. Data evaluating the value of screening patients for latent CARV infections and their impact is limited. This study evaluates the utility of screening LTx recipients for CARV infections. Methods: Retrospective review of all outpatient bronchoscopies on LTx recipients at our Institution between 01.08.2012 and 10.10.2013 was performed. Structured patient questionnaires, routine laboratory, blood gas, spirometry and chest x-rays were evaluated. Bronchoscopies were performed as part of our surveillance programme, elective control procedures or unplanned procedures necessary due to new symptoms, ≥ 10% loss in FEV1, raised inflammatory indices or x-ray change. Bronchoalveolar Lavage (BAL) was performed in all cases and samples sent for microbiological and virological assessment. IFT assays for CARV were performed on all samples. A negative IFT in symptomatic patients resulted in mPCR analysis. Results: 541 patients underwent 1,705 bronchoscopies, of which 773 (45%) were indicated. Median number of procedures was 2 [IQR 1-4] per patient, at median 12.2 [IQR 4.0-27.7] months post-LTx. 177 (10.4%) CARV infections were identified: IFT 87, mPCR 93. Paramyxoviruses accounted for 113/177 (64%) of CARV infections. Eighteen patients (10%) denied symptoms, but exhibited deteriorated lung function or raised CRP. Only 2/630 (0.3%) asymptomatic patients with normal CRP and FEV1 values tested positive. Symptomatic CARV infection increased the likelihood of persisting ≥ 10% FEV1 loss (34 vs. 21%; p= 0.001) at follow-up. Clinically asymptomatic infections demonstrated similar clinical course to CARV negative patients (≥ 10% FEV1 loss; 25 vs. 20%; p= 0.76). Conclusion: Virology screening in asymptomatic stable LTx patients appears unnecessary. Structured history-taking and evaluation of laboratory and spirometry data reliably predicts patients at-risk. Asymptomatic CARV infections appear rare and of limited consequence. 5( 16) A Peritransplant Strategy in Lung Transplant Recipients with Preformed HLA Donor-Specific Antibodies (pDSA) F. Parquin , J. Devaquet, A. Si Larbi, E. Cuquemelle, A. Roux, C. Cerf, C. Picard. Lung Transplant Group, Hopital Foch, Suresnes, France. Purpose: pDSA are associated with acute antibody mediated rejection (AMR) and poor graft outcome after kidney and cardiac transplantation, the risk increasing with the pDSA strenght. Therefore, peritransplant regimen based on combination of plasmapheresis, intravenous immunoglobulin (ivIg) and anti CD20 were successfully developed in presensitised patients (pts) to overcome positive virtual crossmatch. We applied this strategy in lung
Abstracts S193 transplanted pts with pDSA > 1000 (Luminex single Antigen assay) and report the outcome. Methods: In a single center 138 pts underwent primary LT from 01/10 to 11/12, mostly bilateral procedures for cystic fibrosis. 39 pts with low pDSA levels < 1000 were excluded. Pts with pDSA MFI max > 1000 underwent 6 plasmapheresis (1 pre- and 5 post-operatively) then iv Ig (2g/kg) and one administration of rituximab (375 mg/m2). They were compared with patients without pDSA. The post operative course, and the occurrence of definite or possible AMR (DSA and clinical symptoms or immunohistological criteria) were analysed in both groups. Results: Among these 99 pts, 17 pts (17%) had pDSA MFI max > 1000 (MFI 1000 to 5000, n= 10 pts; MFI 5000 to 10 000, n= 6 pts; MFI > 10 000, n= 1 pt). Seven pts had only class I pDSA, 7 only class II pDSA and 3 had both. Lymphocytotoxicity crossmatch was negative in 15 pts and falsely positive in 2 due to prior administration of rituximab. 82 pts (83%) had no pDSA . The median waiting time before LT in pDSA+ pts was 72 d [5;124]. The preoperative and intraoperative characteristics were similar between groups as the one month incidence of bleeding, pulmonary infections, cellular rejection, mechanical ventilation duration and ICU length of stay. At day 30, definite AMR didn’t occurr in pDSA+ pts but one in pDSA- pts. At 1 year no definite or possible AMR was observed in pDSA+ pts vs 4 definite AMR and 2 possible AMR in pDSA- pts. Actuarial survival at follow up was similar between groups (log rank p = 0,3). Conclusion: This strategy allows to transplant pts with pDSA with a short waiting time. This procedure is safe, associated with similar post operative course as pDSA- pts. This high risk group of pts did not develop AMR during the first year. Further studies are needed to assess maintenance therapy, long term outcome and graft survival.
5( 18) 5( 17) Impact of Preoperative Atrial Fibrillation on Outcomes Following Continuous Flow LVAD Implantation D. Stern , M. Follis, J. Nguyen, R. Bello, D. D’Alessandro, D. Goldstein. Cardiovascular and Thoracic Surgery, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. Purpose: Preoperative atrial fibrillation (AF) is a risk factor for increased complications and mortality following valvular and coronary cardiac surgery. Scarce data exists examining complication rates following left ventricular assist device (LVAD) implantation in patients with preoperative AF. We review our institutional experience with patients with preoperative AF who underwent LVAD placement to determine its impact on survival and adverse events. Methods: All patients > 18 years old implanted with continuous flow LVADs at our institution between 6/13/2006 and 4/30/2013 were prospectively entered in an IRB approved database. Data collection continued through 9/30/2013. Patients were maintained on an anticoagulation protocol targeting an INR of 2.0-2.5. Patients with preoperative AF were compared to those without AF. Continuous variables were compared using the Mann-Whitney u-test due to deviation from normality. Categorical variables were compared using Pearson chi-squared test. Results: 120 patients received continuous flow LVADs during the study period. 66 (55%) had preoperative AF while 54 (45%) did not. At baseline, the only significant difference between the groups was the incidence of preoperative CVA in patients with AF. Post-LVAD implant duration of support, length of stay, rates of hemolysis, pump thrombus and GI bleeding were similar. Post-implant neurologic events (CVA, TIA, intracranial hemorrhage) were more common in patients with preoperative AF (27.3% vs 11.1%, p-value < . 05). Mean survival was also shorter in those patients with preoperative AF and approached significance. Conclusion: There was a statistically significant increase in the incidence of neurologic events and a trend toward decreased overall survival in LVAD patients with preoperative AF. Preoperative AF should be carefully considered in risk stratification of LVAD recipients. The addition of anti-arrhythmia procedures and left atrial appendage ligation at LVAD implant may be warranted.
The Clinical Impact of Atrial Fibrillation in Patients with the HeartMate II Left Ventricular Assist Device A.D. Enriquez ,1 C. Brandon,2 P.U. Gandhi,2 A. Nair,2 A. Anyanwu,2 S.P. Pinney.2 1Brigham and Women’s Hospital, Boston, MA; 2Mount Sinai Medical Center, New York, NY. Purpose: Atrial fibrillation (AF) is common in patients with the HeartMate II (HMII) left ventricular assist device (LVAD). However, the clinical consequences of AF in this patient population are uncertain. Methods: Records of 106 patients who underwent implantation of the HMII at a single center were reviewed. The association of AF with survival, heart failure (HF) hospitalization, bleeding and thromboembolism was examined using Kaplan-Meier survival analysis and Cox proportional hazards regression. Results: Mean age was 56.6±11.4 years, 82.1% were male, 42.5% had an ischemic cardiomyopathy, 87.7% were bridge to transplantation and median length of support was 217 days (range 1-952). Twenty-one (19.8%) patients died, and 18 (17.0%) were hospitalized for HF. There were 0.75 major bleeding events and 0.28 thromboembolic events per patient year of follow-up. AF was present in 55 (51.9%) patients; 36 (34.0%) patients had paroxysmal AF and 19 (17.9%) had persistent AF. Patients with AF were more likely to be older, have chronic kidney disease and be diagnosed with HF for > 1 year. Persistent AF was an independent predictor of both increased mortality (HR, 3.22 [1.10-9.36], p= 0.032) and increased hospitalizations for HF (HR, 3.98 [1.32 - 12.02], p= 0.014). However, AF was not associated with an elevated risk of major bleeding (HR, 1.22 [0.59 - 2.51], p= 0.595) or thromboembolism (HR, 0.67 [0.25 - 1.80], p= 0.423), though patients with AF had thromboembolic events at higher international normalized ratios (2.70 ± 0.94 vs. 1.54 ± 0.34, p= 0.003). Conclusion: AF is present in half of patients with the HMII LVAD and is associated with worse outcomes despite the absence of an increased risk of bleeding and thromboembolism. 5( 19) Atrial Fibrillation in Patients Supported by Continuous-Flow Left Ventricular Assist Device A.R. Garan ,1 K.P. Mody,1 A.P. Levine,1 J. Fried,1 M. DionizovikDimanovski,1 M. Yuzefpolskaya,1 P.C. Colombo,1 H. Takayama,2 Y. Naka,2 S. Restaino,1 D.M. Mancini,1 U.P. Jorde,1 N. Uriel.1 1Medicine, Columbia University, New York, NY; 2Surgery, Columbia University, New York, NY.
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
5( 13) Influence of Intraoperative Hemodynamic Factors on the Development of Acute Kidney Injury in Lung Transplantation R. Romano ,1 I. Wong,2 L. Thakuria,2 F. De Robertis,3 T. Bahrami,3 M. Amrani,3 S. Kaul,3 D. Hall,3 A. Reed,3 M. Carby,3 A. Simon,3 N. Marczin.1 1Anaesthetics, Imperial College London, London, United Kingdom; 2Imperial College London, London, United Kingdom; 3Royal Brompton and Harefield NHS Foundation Trust, Harefield, United Kingdom. Purpose: Postoperative renal dysfunction requiring renal replacement therapy occurs frequently following lung transplantation (LT) with impact on perioperative and early mortality. Beyond preoperative factors, intraoperative events may also contribute to renal problems. In search of intraoperative determinants of postoperative renal dysfunction, we have evaluated the impact of hypotension episodes (HE) and requirement for vasoactive support and usage of blood products on the development of postoperative AKI in patients undergoing bilateral sequential lung transplantation. Methods: HE lasting longer than 15 min were graded according to blood pressure targets from the electronic database record (IntelliSpace Critical Care and Anaesthesia) of 60 patients between July 2010 and April 2013 at Harefield Hospital. Vasoactive support was documented at arrival to ICU. The development of AKI was monitored during the first 3 postoperative days using AKI Network (AKIN) criteria. Results: The development of AKI was associated with more HE below the target mean arterial blood pressure of 70 mmHg (16.7 ± 8.4 vs 11.1± 3.0 p= 0.019). In addition, the frequency of HE was also related to the grading of AKI (11.1 ± 3.0; 13.0 ± 5.2; 15.0 ± 7.9 and 19.9 ± 9.5 for AKI 0, 1, 2 and 3, respectively , p= 0.013). Similarly, episodes of mean arterial blood pressure < 60 mmHg was also different between AKI and no AKI groups (5.7 ± 5.6 vs 2.1 ± 1.9, p= 0.042). HE in patients subjected to cardiopulmonary bypass was higher (16.9 ± 9.1 vs 11.5 ± 6.8 for MAP< 70 and 6.0 ± 5.6 vs 1.6 ± 1.9 for MAP< 60, p= 0.001) associated with higher incidence of grade 3 AKI (51.1% vs 7.7). Regarding vasoactive support, the use of milrinone, noradrenaline and vasopressin was higher in patients who developed AKI. AKI was also associated with higher use of blood products (5.2 vs 2.9 U for red blood cells; 2.6 vs 1.4 U for plasma and 1.3 vs 0.57 U for platelets). Conclusion: This study highlights the potential role of intraoperative factors in the development of AKI following LT. Lasting intraoperative hypotension requiring higher doses of vasoactive support, the use of cardiopulmonary bypass and increased blood transfusion appear to be associated with higher incidence and severity of AKI. These may have important implications to overall intraoperative management of LT. 5( 14) Outcome After Transplantation of Lungs Evaluated With Ex-Vivo Lung Perfusion A. Wallinder ,1 S. Ricksten,2 G.C. Riise,3 T. Nilsson,4 G. Dellgren.3 1Dep. of Cardiothoracic surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; 2Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden; 3Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden; 4Cardiothoracic Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden. Purpose: Ex vivo lung perfusion (EVLP) has emerged as a reliable method for evaluation of rejected donor lungs and is now adopted by several institutions. We reviewed clinical outcome in patients transplanted with EVLP evaluated lungs at our centre and compared results to contemporary controls. Methods: Lungs deemed unsuitable for donation but with potential for improvement underwent EVLP and were transplanted if preset criteria was fulfilled. Clinical outcome was reviewed and compared to consecutive patients transplanted during the same time period with conventional donor lungs (CONV). Results: 22 donor lungs were initially rejected for Lung transplantation (Ltx) due to inferior PaO2/FiO2 ratio (n= 15), bilateral infiltrate on chest x-ray (n= 11) or on going ECMO (n= 1). Four double lungs and two single lungs were deemed unsuitable for transplantation. 18 recipients from the regular waiting list underwent either lobar (n= 1) single (n= 4) or double (n= 13) LTx with EVLP-treated lungs. Data was compared to 85 consecutive recipients of
non-EVLP lungs. Primary graft dysfunction > grade 1 at 72 hours occurred in 16% of patients in the EVLP group and 12% in the CONV group. Median ICU stay was for the EVLP group 73 hours (range, 36-936) and for CONV group51 hours (range, 19-1632), p= 0.58. There was no difference in length of hospital stay (p= 0.21). Survival, free from graft-loss, was 83% at one year in the EVLP group and 85% in the CONV group (fig. 1). Between 12 and 18 months one recipient in the EVLP group was re-transplanted and one patient transplanted with lobes died from a pulmonary embolization. At 12 months median FEV 1.0 (% of predicted) was 98% (EVLP) and 96% (CONV) for double lung recipients compared to 53% (EVLP) and 59% (CONV) for single lung recipients. Conclusion: Results after transplantation of lungs after EVLP seem noninferior to results after conventional transplantation. This finding is congruent with data from other centres. 5( 15) Is Routine Screening for Community-Acquired Respiratory Virus Infections in Lung Transplant Recipients Worthwhile? M. Greer ,1 T. Fühner,1 I. Tudorache,2 G. Warnecke,2 A. Haverich,2 T. Welte,1 J. Gottlieb.1 1Respiratory Medicine, Hanover Medical School, Hannover, Germany; 2Cardiac, Thoracic, Transplantation and Vascular Surgery, Hanover Medical School, Hannover, Germany. Purpose: Community-acquired respiratory virus (CARV) infections increase morbidity and mortality among lung transplant (LTx) recipients. Reported prevalence rates approach 9%, with detection traditionally relying on antigen testing e.g. immunofluorescence assays (IFT). Recently multiplex-PCR (mPCR) has shown better sensitivity in virus detection. Data evaluating the value of screening patients for latent CARV infections and their impact is limited. This study evaluates the utility of screening LTx recipients for CARV infections. Methods: Retrospective review of all outpatient bronchoscopies on LTx recipients at our Institution between 01.08.2012 and 10.10.2013 was performed. Structured patient questionnaires, routine laboratory, blood gas, spirometry and chest x-rays were evaluated. Bronchoscopies were performed as part of our surveillance programme, elective control procedures or unplanned procedures necessary due to new symptoms, ≥ 10% loss in FEV1, raised inflammatory indices or x-ray change. Bronchoalveolar Lavage (BAL) was performed in all cases and samples sent for microbiological and virological assessment. IFT assays for CARV were performed on all samples. A negative IFT in symptomatic patients resulted in mPCR analysis. Results: 541 patients underwent 1,705 bronchoscopies, of which 773 (45%) were indicated. Median number of procedures was 2 [IQR 1-4] per patient, at median 12.2 [IQR 4.0-27.7] months post-LTx. 177 (10.4%) CARV infections were identified: IFT 87, mPCR 93. Paramyxoviruses accounted for 113/177 (64%) of CARV infections. Eighteen patients (10%) denied symptoms, but exhibited deteriorated lung function or raised CRP. Only 2/630 (0.3%) asymptomatic patients with normal CRP and FEV1 values tested positive. Symptomatic CARV infection increased the likelihood of persisting ≥ 10% FEV1 loss (34 vs. 21%; p= 0.001) at follow-up. Clinically asymptomatic infections demonstrated similar clinical course to CARV negative patients (≥ 10% FEV1 loss; 25 vs. 20%; p= 0.76). Conclusion: Virology screening in asymptomatic stable LTx patients appears unnecessary. Structured history-taking and evaluation of laboratory and spirometry data reliably predicts patients at-risk. Asymptomatic CARV infections appear rare and of limited consequence. 5( 16) A Peritransplant Strategy in Lung Transplant Recipients with Preformed HLA Donor-Specific Antibodies (pDSA) F. Parquin , J. Devaquet, A. Si Larbi, E. Cuquemelle, A. Roux, C. Cerf, C. Picard. Lung Transplant Group, Hopital Foch, Suresnes, France. Purpose: pDSA are associated with acute antibody mediated rejection (AMR) and poor graft outcome after kidney and cardiac transplantation, the risk increasing with the pDSA strenght. Therefore, peritransplant regimen based on combination of plasmapheresis, intravenous immunoglobulin (ivIg) and anti CD20 were successfully developed in presensitised patients (pts) to overcome positive virtual crossmatch. We applied this strategy in lung
Abstracts S193 transplanted pts with pDSA > 1000 (Luminex single Antigen assay) and report the outcome. Methods: In a single center 138 pts underwent primary LT from 01/10 to 11/12, mostly bilateral procedures for cystic fibrosis. 39 pts with low pDSA levels < 1000 were excluded. Pts with pDSA MFI max > 1000 underwent 6 plasmapheresis (1 pre- and 5 post-operatively) then iv Ig (2g/kg) and one administration of rituximab (375 mg/m2). They were compared with patients without pDSA. The post operative course, and the occurrence of definite or possible AMR (DSA and clinical symptoms or immunohistological criteria) were analysed in both groups. Results: Among these 99 pts, 17 pts (17%) had pDSA MFI max > 1000 (MFI 1000 to 5000, n= 10 pts; MFI 5000 to 10 000, n= 6 pts; MFI > 10 000, n= 1 pt). Seven pts had only class I pDSA, 7 only class II pDSA and 3 had both. Lymphocytotoxicity crossmatch was negative in 15 pts and falsely positive in 2 due to prior administration of rituximab. 82 pts (83%) had no pDSA . The median waiting time before LT in pDSA+ pts was 72 d [5;124]. The preoperative and intraoperative characteristics were similar between groups as the one month incidence of bleeding, pulmonary infections, cellular rejection, mechanical ventilation duration and ICU length of stay. At day 30, definite AMR didn’t occurr in pDSA+ pts but one in pDSA- pts. At 1 year no definite or possible AMR was observed in pDSA+ pts vs 4 definite AMR and 2 possible AMR in pDSA- pts. Actuarial survival at follow up was similar between groups (log rank p = 0,3). Conclusion: This strategy allows to transplant pts with pDSA with a short waiting time. This procedure is safe, associated with similar post operative course as pDSA- pts. This high risk group of pts did not develop AMR during the first year. Further studies are needed to assess maintenance therapy, long term outcome and graft survival.
5( 18) 5( 17) Impact of Preoperative Atrial Fibrillation on Outcomes Following Continuous Flow LVAD Implantation D. Stern , M. Follis, J. Nguyen, R. Bello, D. D’Alessandro, D. Goldstein. Cardiovascular and Thoracic Surgery, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. Purpose: Preoperative atrial fibrillation (AF) is a risk factor for increased complications and mortality following valvular and coronary cardiac surgery. Scarce data exists examining complication rates following left ventricular assist device (LVAD) implantation in patients with preoperative AF. We review our institutional experience with patients with preoperative AF who underwent LVAD placement to determine its impact on survival and adverse events. Methods: All patients > 18 years old implanted with continuous flow LVADs at our institution between 6/13/2006 and 4/30/2013 were prospectively entered in an IRB approved database. Data collection continued through 9/30/2013. Patients were maintained on an anticoagulation protocol targeting an INR of 2.0-2.5. Patients with preoperative AF were compared to those without AF. Continuous variables were compared using the Mann-Whitney u-test due to deviation from normality. Categorical variables were compared using Pearson chi-squared test. Results: 120 patients received continuous flow LVADs during the study period. 66 (55%) had preoperative AF while 54 (45%) did not. At baseline, the only significant difference between the groups was the incidence of preoperative CVA in patients with AF. Post-LVAD implant duration of support, length of stay, rates of hemolysis, pump thrombus and GI bleeding were similar. Post-implant neurologic events (CVA, TIA, intracranial hemorrhage) were more common in patients with preoperative AF (27.3% vs 11.1%, p-value < . 05). Mean survival was also shorter in those patients with preoperative AF and approached significance. Conclusion: There was a statistically significant increase in the incidence of neurologic events and a trend toward decreased overall survival in LVAD patients with preoperative AF. Preoperative AF should be carefully considered in risk stratification of LVAD recipients. The addition of anti-arrhythmia procedures and left atrial appendage ligation at LVAD implant may be warranted.
The Clinical Impact of Atrial Fibrillation in Patients with the HeartMate II Left Ventricular Assist Device A.D. Enriquez ,1 C. Brandon,2 P.U. Gandhi,2 A. Nair,2 A. Anyanwu,2 S.P. Pinney.2 1Brigham and Women’s Hospital, Boston, MA; 2Mount Sinai Medical Center, New York, NY. Purpose: Atrial fibrillation (AF) is common in patients with the HeartMate II (HMII) left ventricular assist device (LVAD). However, the clinical consequences of AF in this patient population are uncertain. Methods: Records of 106 patients who underwent implantation of the HMII at a single center were reviewed. The association of AF with survival, heart failure (HF) hospitalization, bleeding and thromboembolism was examined using Kaplan-Meier survival analysis and Cox proportional hazards regression. Results: Mean age was 56.6±11.4 years, 82.1% were male, 42.5% had an ischemic cardiomyopathy, 87.7% were bridge to transplantation and median length of support was 217 days (range 1-952). Twenty-one (19.8%) patients died, and 18 (17.0%) were hospitalized for HF. There were 0.75 major bleeding events and 0.28 thromboembolic events per patient year of follow-up. AF was present in 55 (51.9%) patients; 36 (34.0%) patients had paroxysmal AF and 19 (17.9%) had persistent AF. Patients with AF were more likely to be older, have chronic kidney disease and be diagnosed with HF for > 1 year. Persistent AF was an independent predictor of both increased mortality (HR, 3.22 [1.10-9.36], p= 0.032) and increased hospitalizations for HF (HR, 3.98 [1.32 - 12.02], p= 0.014). However, AF was not associated with an elevated risk of major bleeding (HR, 1.22 [0.59 - 2.51], p= 0.595) or thromboembolism (HR, 0.67 [0.25 - 1.80], p= 0.423), though patients with AF had thromboembolic events at higher international normalized ratios (2.70 ± 0.94 vs. 1.54 ± 0.34, p= 0.003). Conclusion: AF is present in half of patients with the HMII LVAD and is associated with worse outcomes despite the absence of an increased risk of bleeding and thromboembolism. 5( 19) Atrial Fibrillation in Patients Supported by Continuous-Flow Left Ventricular Assist Device A.R. Garan ,1 K.P. Mody,1 A.P. Levine,1 J. Fried,1 M. DionizovikDimanovski,1 M. Yuzefpolskaya,1 P.C. Colombo,1 H. Takayama,2 Y. Naka,2 S. Restaino,1 D.M. Mancini,1 U.P. Jorde,1 N. Uriel.1 1Medicine, Columbia University, New York, NY; 2Surgery, Columbia University, New York, NY.