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Intracranial Hemorrage in Patients with Continous Flow LVAD
Abstracts Conclusion: Our data suggest that there is no evident increased risk or compromised post-transplant outcomes in performing side-mismatched single LTx when appropriate lung graft as well as intraoperative cardiopulmonary support is chosen. This strategy could optimize organ utilization increasing effective organ supply and decreasing waitlist mortality. In addition, this may contribute to avoiding the surgical or anatomical complexity leading to improved transplant outcomes.
1062 Comparison of Oto, MALT and ET-Score in Predicting Outcome after Lung Transplantation - A Large Single-Center Cohort Study S. Schwarz, N. Rahimi, M. Muckenhuber, A. Benazzo, B. Moser, J.R. Matilla, G. Lang, S. Taghavi, P. Jaksch, W. Klepetko and K. Hoetzenecker. Thoracic Surgery, Medical University of Vienna, Vienna, Austria. Purpose: The increasing use of marginal donor organs has created the demand for reliable predictors of outcome. Several scoring systems have been proposed, however, at present, none of them have gained widespread use in lung transplantation. Herein, we aimed to compare three scoring systems and their accuracy in predicting posttransplant outcome. Methods: We analysed a total of 844 patients who received standard double lung transplantation between January 2010 and June 2018 in our institution. Three scores were calculated for each patient: Oto’s donor score as proposed in 2007 includes donor age, smoking history, chest x-ray, secretions in bronchoscopy and PaO2/FiO2. The ET score published in 2011 added ‘donor history’ parameters to these variables. The MALT-score was created with the main goal to predict 1-year mortality. In contrast to the other scores it also includes recipient factors such as age, KPS-score, GFR, serum albumin and CMV risk status. Short- and long-term outcomes based on these three scores were compared. Results: Duration of mechanical ventilation (DMV) could not be predicted by the Oto score (high vs low; p=0.567). However, high risk MALT score patients had significantly longer DMV compared to intermediate and low risk patients (p<0.001). The three classes of the ET-score were also predictive for DMV (p=0.013). The MALT-score resulted in the best prediction of long-term survival (1year: low risk 89.8%, intermediate risk 82.1%, high risk 74.7%; 5-year: low risk 80.3%, intermediate risk: 69.9%, high risk: 68.4%; p<0.001). Oto’s score showed a trend towards improved survival using donors with a low compared to a high risk score (1-year survival: 87.1% vs 80.0% and 5year 77.6% vs 68.7% (p=0.087)). The ET-score failed to predict long-term survival (p=0.149) Conclusion: In this large single-center cohort, the MALT score was superior in predicting post-transplant outcomes when compared to Oto’s score and the ET-score, which both exclusively include donor variables.
S421 1063 Survival for Combined Heart-Lung Transplant (HLT) Recipients over the Past 30 Years C.J. Lum,1 W. Ragalie,1 R. Chand,1 A. Salimbangon,1 A. Chang,1 T. Khuu,1 M. Cadeiras,2 M. Deng,1 D. Vucicevic,3 K. Pandya,4 A. Ardehali,1 A. Ardehali,1 and E. DePasquale.1 1University of California, Los Angeles, Los Angeles, CA; 2University of California, Davis, Davis, CA; 3 Newark Beth Israel, Newark, NJ; and the 4University of Southern California, Los Angeles, CA. Purpose: Comparison outcomes in HLT recipients have not been well described over time. We sought to investigate the impact of era in HLT survival (ERA1: 1987-1998 & ERA2: 1999-2018). Methods: We conducted a retrospective, cohort analysis of the UNOS Registry of all HLT patients between 1987-2018, comparing mortality rates between ERA1 & ERA2. Exclusions include age<18y, follow-up loss, redo & multi-organ transplants (besides HLT). Survival was censored at 12y & multivariate Cox proportional hazard regression analysis (adjusted for age, sex, diabetes, race, ischemic time, dialysis, life support, waiting time & HLA mismatch) was performed. Results: 1132 HLT pts were identified from 1987-2018, of which 584 and 548 underwent HLT during ERA1 & ERA2, respectively. ERA2 recipients were more likely to be older (36.9 § 15.8y vs 32.3 § 14.1y, p<0.001), have prior cardiac surgery (17% vs 0%, p<0.001), receive older donors (28.3 § 14.4y vs 23.3 § 12.9y, p<0.001) with increased pre-HLT dialysis use (2.7% vs 0%, p<0.001). Waitlist time was also shorter in ERA2 (137d (IQR 38-402) vs 214d (IQR71-469d), p<0.001). Overall survival is shown in Figure. Mortality at 12y was 89% & 60%, respectively for ERA1 & 2 (p=0.001). Unadjusted hazard ratio for ERA2 compared to ERA1 was 0.72 (95% CI 0.622-0.834) & 0.68 (95% CI 0.561-0.818) following adjustment. Additionally, while death due to infection decreased from ERA2 to 1 (15.2 vs 23.3%), graft failure increased (11.3 vs 6.9%) (p=0.001). Conclusion: Overall, HLT survival improved in the more recent era despite higher risk characteristics. Improvement in survival is likely multifactorial with improved patient selection, surgical technique and post-HLT immunosuppressive management. Further study is warranted to better understand and improve outcomes.
S422
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
1064
Furthermore, Japanese patients had higher markers of inflammation with 4fold higher IL-8 and 2-fold higher TNF-a (Table 1B). Conclusion: Different rate of comorbidities between US and Japan are associated with the different expression of inflammatory and angiogenesis biomarkers. Longitudinal studies focusing on these biomarker levels are warranted.
Intracranial Hemorrage in Patients with Continous Flow LVAD € urk,2 E. Simsek,1 C. Engin,2 T. Ya E. Demir,1 S. Nalbantgil,1 P. Ozt€ gd{,2 2 1 € _ and M. Ozbaran. Cardiology, Ege University Medicine Faculty, Izmir, Turkey; and the 2Cardiovascular Surgery, Ege University Medicine _ Faculty, Izmir, Turkey. Purpose: Patients with left ventricular assist devices (LVAD) are at high risk of cerebrovascular events, including stroke and intracranial hemorrage (ICH). There is limited data available on risk factors and outcome associated with CNI events in LVAD population. In this study the incidence of ICH, outcome and associated risk factors were evaluated. Methods: 340 patients implanted with continuous-flow LVAD from the year 2012 to 2018 were included in the study. Results: During this time interval, 46 patients had ICH and the incidence rate of ICH was 0.022 per patient-year. ICH patients’ mean age was 50.7 § 11.8 years and 41 (89.1%) patients were men. The incidence of ICH was 14.3% (n=46). 15.2% of the events were hemorragic transformation after stroke, 8.7% were associated with high INR values, 13.6% developed after thrombolytic therapy for pump thrombosis and 63% were spontaneous (without any established predisposition). Traditional risk factors weren’t determinative of hemorrhagic stroke events. 13.1% of ICH patients had a previous CNI event before LVAD implantation. The previous CNI event (whether an ischemic stroke or ICH) before LVAD implantation wasn’t associated with postop of ICH. 76% of the spontaneous ICH patients had nonischemic cmp. This number was significantly higher than patients with ischemic origin (76% and 24% respectively p=0.047). ICH related mortality rate was 45.7%. Mortality mostly occurred in hemorrhagic transformation stroke patients (83.3%). Mortality rate was 34.5 % in spontaneous ICH patients. Death was significantly higher in ischemic cmp patients than in nonischemic population (63.6%30.4% respectively, p=0.026) 41.4% of the spontaneous ICH patients had positive blood cultures within the previous 30 days or 7 days after the ICH event. The most frequent pathogen that caused bacteremia was gram-positive (75%) and the most frequent established pathogen was Staphylococcus aureus (41.7%). Another condition associated with spontaneous bleeding was bacteriemia due to driveline infection (75% n=9, p=0.001). The most frequent pathogen that caused bacteremia was gram-positive bacteria(75%) and the most frequent established pathogen was Staphylococcus aureus (41.7%). Conclusion: ICH seen after LVAD implantation is associated with high mortality rates. Infection with positive blood cultures is a strong risk factor for ICH. Nonischemic cmp patients were found to be at higher risk.
1065 Comorbidities and Biomarkers Vary between United States and Japanese LVAD Patients T. Imamura,1 A. Nguyen,1 D. Nitta,1 T. Fujino,1 L. Holzhauser,1 D. Rodgers,1 S. Kalantari,1 B. Smith,1 J. Raikhelkar,1 N. Narang,1 B. Chung,1 I. Ebong,1 C. Juricek,1 P. Combs,1 D. Onsager,1 T. Song,1 T. Ota,1 V. Jeevanandam,1 G. Kim,1 G. Sayer,1 M. Ono,2 and N. Uriel.1 1University of Chicago, Chicago, IL; and the 2University of Tokyo, Tokyo, Japan. Purpose: Left ventricular assist device (LVAD) outcomes differ between Japan and US. While GI bleeding is common in US and rare in Japan, stroke and driveline infections are more common in Japan than US. The aim of this study was to explore whether inflammatory and angiogenesis biomarkers can explain these differences. Methods: Plasma levels of inflammatory and angiogenetic biomarkers were measured with Bio-plex ProTM Biomarker Assay kits. Levels were compared between US and Japanese LVAD patients. Adverse event rates were also compared between the two countries using binomial negative regression analysis. Results: 61 patients were enrolled. The US cohort (N=38) was older (56.4 vs. 42.4 years; p <0.05) and had more women (34% vs. 5%; p <0.05) compared to the Japanese cohort (N=23). Plasma samples were drawn at similar time following LVAD implantation (median 470 vs. 550 days; p=0.68). GIB rate was significantly higher in the US cohort (0.286 vs. 0.023 event/year; p <0.001). Stroke rate (0.052 vs. 0.218 event/year, p <0.001) and driveline infection rate (0.071 vs. 0.184 event/year, p <0.001) were significantly lower in the US cohort. Japanese patients had elevated angiogenesis parameters including 4fold higher angiopoietin-2 levels (823 vs. 172 pg/mL, p <0.001; Table 1A).
1066 Comparison of Unfractionated Heparin and Bivalirudin for Treatment of Suspected Device Thrombosis during Heart Mate II Support K. Shah,1 D.B. Sims,1 S. Forest,2 T. Chinnadurai,1 Y. Xia,2 A. Luke,1 D. Nnani,3 C. Castillo,1 M. Taveras,1 S. Vukelic,1 S.R. Patel,1 J. Shin,1 D.J. Goldstein,2 U.P. Jorde,1 and O. Saeed.1 1Medicine (Cardiology), Montefiore Medical Center, Bronx, NY; 2Cardiothoracic Surgery, Montefiore Medical Center, Bronx, NY; and the 3Pharmacy, Montefiore Medical Center, Bronx, NY. Purpose: Although intravenous anticoagulation is the mainstay medical therapy employed during CF LVAD thrombosis, the comparative impact of indirect thrombin inhibition with unfractionated heparin (UH) and direct thrombin inhibition with bivalirudin (BV) is unknown. Methods: We conducted a single center review of all patients with a Heart Mate(HM) II who were admitted for suspected device thrombosis (SDT) from September 2011 to September 2018. Device thrombosis was suspected due to elevated outpatient lactate dehydrogenase (LDH), evidence of systemic emboli, or device alarms. After admission, patients were categorized into those receiving UH or BV. Crossovers were excluded. Freedom from device exchange was calculated with Kaplan Meier analysis. Results: Twenty-three patients were admitted for SDT, of whom 13 received UH and 10 received BV. There were no differences in age (UH: 49.2 vs. BV: 46.9 years, p=0.60) and time from implant to SDT (UH: 10.3 vs. BV: 10.4 months, p=0.98). LDH remained elevated after UH (879, IQR: 755-1049 to 1028, IQR: 550-1438 U/L, p=0.34) but dropped with BV (839, IQR: 733-914 to 453, IQR: 352-465 U/L, p=0.002). During the follow up period, there was a lower likelihood of a device exchange in patients treated with BV (HR: 0.28, 95% CI: 0.09-0.89, p=0.04, figure 1). Conclusion: In this sample of HM II patients, intravenous direct thrombin inhibition was more effective in treating device thrombosis.
1062 Comparison of Oto, MALT and ET-Score in Predicting Outcome after Lung Transplantation - A Large Single-Center Cohort Study S. Schwarz, N. Rahimi, M. Muckenhuber, A. Benazzo, B. Moser, J.R. Matilla, G. Lang, S. Taghavi, P. Jaksch, W. Klepetko and K. Hoetzenecker. Thoracic Surgery, Medical University of Vienna, Vienna, Austria. Purpose: The increasing use of marginal donor organs has created the demand for reliable predictors of outcome. Several scoring systems have been proposed, however, at present, none of them have gained widespread use in lung transplantation. Herein, we aimed to compare three scoring systems and their accuracy in predicting posttransplant outcome. Methods: We analysed a total of 844 patients who received standard double lung transplantation between January 2010 and June 2018 in our institution. Three scores were calculated for each patient: Oto’s donor score as proposed in 2007 includes donor age, smoking history, chest x-ray, secretions in bronchoscopy and PaO2/FiO2. The ET score published in 2011 added ‘donor history’ parameters to these variables. The MALT-score was created with the main goal to predict 1-year mortality. In contrast to the other scores it also includes recipient factors such as age, KPS-score, GFR, serum albumin and CMV risk status. Short- and long-term outcomes based on these three scores were compared. Results: Duration of mechanical ventilation (DMV) could not be predicted by the Oto score (high vs low; p=0.567). However, high risk MALT score patients had significantly longer DMV compared to intermediate and low risk patients (p<0.001). The three classes of the ET-score were also predictive for DMV (p=0.013). The MALT-score resulted in the best prediction of long-term survival (1year: low risk 89.8%, intermediate risk 82.1%, high risk 74.7%; 5-year: low risk 80.3%, intermediate risk: 69.9%, high risk: 68.4%; p<0.001). Oto’s score showed a trend towards improved survival using donors with a low compared to a high risk score (1-year survival: 87.1% vs 80.0% and 5year 77.6% vs 68.7% (p=0.087)). The ET-score failed to predict long-term survival (p=0.149) Conclusion: In this large single-center cohort, the MALT score was superior in predicting post-transplant outcomes when compared to Oto’s score and the ET-score, which both exclusively include donor variables.
S421 1063 Survival for Combined Heart-Lung Transplant (HLT) Recipients over the Past 30 Years C.J. Lum,1 W. Ragalie,1 R. Chand,1 A. Salimbangon,1 A. Chang,1 T. Khuu,1 M. Cadeiras,2 M. Deng,1 D. Vucicevic,3 K. Pandya,4 A. Ardehali,1 A. Ardehali,1 and E. DePasquale.1 1University of California, Los Angeles, Los Angeles, CA; 2University of California, Davis, Davis, CA; 3 Newark Beth Israel, Newark, NJ; and the 4University of Southern California, Los Angeles, CA. Purpose: Comparison outcomes in HLT recipients have not been well described over time. We sought to investigate the impact of era in HLT survival (ERA1: 1987-1998 & ERA2: 1999-2018). Methods: We conducted a retrospective, cohort analysis of the UNOS Registry of all HLT patients between 1987-2018, comparing mortality rates between ERA1 & ERA2. Exclusions include age<18y, follow-up loss, redo & multi-organ transplants (besides HLT). Survival was censored at 12y & multivariate Cox proportional hazard regression analysis (adjusted for age, sex, diabetes, race, ischemic time, dialysis, life support, waiting time & HLA mismatch) was performed. Results: 1132 HLT pts were identified from 1987-2018, of which 584 and 548 underwent HLT during ERA1 & ERA2, respectively. ERA2 recipients were more likely to be older (36.9 § 15.8y vs 32.3 § 14.1y, p<0.001), have prior cardiac surgery (17% vs 0%, p<0.001), receive older donors (28.3 § 14.4y vs 23.3 § 12.9y, p<0.001) with increased pre-HLT dialysis use (2.7% vs 0%, p<0.001). Waitlist time was also shorter in ERA2 (137d (IQR 38-402) vs 214d (IQR71-469d), p<0.001). Overall survival is shown in Figure. Mortality at 12y was 89% & 60%, respectively for ERA1 & 2 (p=0.001). Unadjusted hazard ratio for ERA2 compared to ERA1 was 0.72 (95% CI 0.622-0.834) & 0.68 (95% CI 0.561-0.818) following adjustment. Additionally, while death due to infection decreased from ERA2 to 1 (15.2 vs 23.3%), graft failure increased (11.3 vs 6.9%) (p=0.001). Conclusion: Overall, HLT survival improved in the more recent era despite higher risk characteristics. Improvement in survival is likely multifactorial with improved patient selection, surgical technique and post-HLT immunosuppressive management. Further study is warranted to better understand and improve outcomes.
S422
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
1064
Furthermore, Japanese patients had higher markers of inflammation with 4fold higher IL-8 and 2-fold higher TNF-a (Table 1B). Conclusion: Different rate of comorbidities between US and Japan are associated with the different expression of inflammatory and angiogenesis biomarkers. Longitudinal studies focusing on these biomarker levels are warranted.
Intracranial Hemorrage in Patients with Continous Flow LVAD € urk,2 E. Simsek,1 C. Engin,2 T. Ya E. Demir,1 S. Nalbantgil,1 P. Ozt€ gd{,2 2 1 € _ and M. Ozbaran. Cardiology, Ege University Medicine Faculty, Izmir, Turkey; and the 2Cardiovascular Surgery, Ege University Medicine _ Faculty, Izmir, Turkey. Purpose: Patients with left ventricular assist devices (LVAD) are at high risk of cerebrovascular events, including stroke and intracranial hemorrage (ICH). There is limited data available on risk factors and outcome associated with CNI events in LVAD population. In this study the incidence of ICH, outcome and associated risk factors were evaluated. Methods: 340 patients implanted with continuous-flow LVAD from the year 2012 to 2018 were included in the study. Results: During this time interval, 46 patients had ICH and the incidence rate of ICH was 0.022 per patient-year. ICH patients’ mean age was 50.7 § 11.8 years and 41 (89.1%) patients were men. The incidence of ICH was 14.3% (n=46). 15.2% of the events were hemorragic transformation after stroke, 8.7% were associated with high INR values, 13.6% developed after thrombolytic therapy for pump thrombosis and 63% were spontaneous (without any established predisposition). Traditional risk factors weren’t determinative of hemorrhagic stroke events. 13.1% of ICH patients had a previous CNI event before LVAD implantation. The previous CNI event (whether an ischemic stroke or ICH) before LVAD implantation wasn’t associated with postop of ICH. 76% of the spontaneous ICH patients had nonischemic cmp. This number was significantly higher than patients with ischemic origin (76% and 24% respectively p=0.047). ICH related mortality rate was 45.7%. Mortality mostly occurred in hemorrhagic transformation stroke patients (83.3%). Mortality rate was 34.5 % in spontaneous ICH patients. Death was significantly higher in ischemic cmp patients than in nonischemic population (63.6%30.4% respectively, p=0.026) 41.4% of the spontaneous ICH patients had positive blood cultures within the previous 30 days or 7 days after the ICH event. The most frequent pathogen that caused bacteremia was gram-positive (75%) and the most frequent established pathogen was Staphylococcus aureus (41.7%). Another condition associated with spontaneous bleeding was bacteriemia due to driveline infection (75% n=9, p=0.001). The most frequent pathogen that caused bacteremia was gram-positive bacteria(75%) and the most frequent established pathogen was Staphylococcus aureus (41.7%). Conclusion: ICH seen after LVAD implantation is associated with high mortality rates. Infection with positive blood cultures is a strong risk factor for ICH. Nonischemic cmp patients were found to be at higher risk.
1065 Comorbidities and Biomarkers Vary between United States and Japanese LVAD Patients T. Imamura,1 A. Nguyen,1 D. Nitta,1 T. Fujino,1 L. Holzhauser,1 D. Rodgers,1 S. Kalantari,1 B. Smith,1 J. Raikhelkar,1 N. Narang,1 B. Chung,1 I. Ebong,1 C. Juricek,1 P. Combs,1 D. Onsager,1 T. Song,1 T. Ota,1 V. Jeevanandam,1 G. Kim,1 G. Sayer,1 M. Ono,2 and N. Uriel.1 1University of Chicago, Chicago, IL; and the 2University of Tokyo, Tokyo, Japan. Purpose: Left ventricular assist device (LVAD) outcomes differ between Japan and US. While GI bleeding is common in US and rare in Japan, stroke and driveline infections are more common in Japan than US. The aim of this study was to explore whether inflammatory and angiogenesis biomarkers can explain these differences. Methods: Plasma levels of inflammatory and angiogenetic biomarkers were measured with Bio-plex ProTM Biomarker Assay kits. Levels were compared between US and Japanese LVAD patients. Adverse event rates were also compared between the two countries using binomial negative regression analysis. Results: 61 patients were enrolled. The US cohort (N=38) was older (56.4 vs. 42.4 years; p <0.05) and had more women (34% vs. 5%; p <0.05) compared to the Japanese cohort (N=23). Plasma samples were drawn at similar time following LVAD implantation (median 470 vs. 550 days; p=0.68). GIB rate was significantly higher in the US cohort (0.286 vs. 0.023 event/year; p <0.001). Stroke rate (0.052 vs. 0.218 event/year, p <0.001) and driveline infection rate (0.071 vs. 0.184 event/year, p <0.001) were significantly lower in the US cohort. Japanese patients had elevated angiogenesis parameters including 4fold higher angiopoietin-2 levels (823 vs. 172 pg/mL, p <0.001; Table 1A).
1066 Comparison of Unfractionated Heparin and Bivalirudin for Treatment of Suspected Device Thrombosis during Heart Mate II Support K. Shah,1 D.B. Sims,1 S. Forest,2 T. Chinnadurai,1 Y. Xia,2 A. Luke,1 D. Nnani,3 C. Castillo,1 M. Taveras,1 S. Vukelic,1 S.R. Patel,1 J. Shin,1 D.J. Goldstein,2 U.P. Jorde,1 and O. Saeed.1 1Medicine (Cardiology), Montefiore Medical Center, Bronx, NY; 2Cardiothoracic Surgery, Montefiore Medical Center, Bronx, NY; and the 3Pharmacy, Montefiore Medical Center, Bronx, NY. Purpose: Although intravenous anticoagulation is the mainstay medical therapy employed during CF LVAD thrombosis, the comparative impact of indirect thrombin inhibition with unfractionated heparin (UH) and direct thrombin inhibition with bivalirudin (BV) is unknown. Methods: We conducted a single center review of all patients with a Heart Mate(HM) II who were admitted for suspected device thrombosis (SDT) from September 2011 to September 2018. Device thrombosis was suspected due to elevated outpatient lactate dehydrogenase (LDH), evidence of systemic emboli, or device alarms. After admission, patients were categorized into those receiving UH or BV. Crossovers were excluded. Freedom from device exchange was calculated with Kaplan Meier analysis. Results: Twenty-three patients were admitted for SDT, of whom 13 received UH and 10 received BV. There were no differences in age (UH: 49.2 vs. BV: 46.9 years, p=0.60) and time from implant to SDT (UH: 10.3 vs. BV: 10.4 months, p=0.98). LDH remained elevated after UH (879, IQR: 755-1049 to 1028, IQR: 550-1438 U/L, p=0.34) but dropped with BV (839, IQR: 733-914 to 453, IQR: 352-465 U/L, p=0.002). During the follow up period, there was a lower likelihood of a device exchange in patients treated with BV (HR: 0.28, 95% CI: 0.09-0.89, p=0.04, figure 1). Conclusion: In this sample of HM II patients, intravenous direct thrombin inhibition was more effective in treating device thrombosis.