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Prolonged Corrected QT Interval in the Donor Heart: Is There a Risk?
S60
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
of delisting for clinical worsening in the CF-LVAD cohort was 0.171 per patient year compared to 0.087 per patient year (p< 0.001). The incidence of VAD implantation in patients primarily medically bridged to transplantation was 0.217 per patient year. Two year survival after listing was lower in the CF-LVAD cohort (79.38 % vs 89.01; p< 0.001). Conclusion: We here present competing outcomes for heart transplant candidates bridged with and without VAD to transplantation after time of listing for heart transplantation. The overall outcomes including post-transplant survival were lower in the CF-LVAD cohort. The incidence for delisting from the waiting due to clinical worsening was higher in the CF-LVAD cohort. However, it needs to be emphasized that these are registry data, but prospective studies might help to best inform heart transplant candidates in their overall chance for survival after time they get listed. 1( 40) Prolonged Corrected QT Interval in the Donor Heart: Is There a Risk? J. Patel , M. Kittleson, L. Czer, T. Aintablian, D. Phan, D. Leong, J. Rush, E. Stimpson, D. Chang, A. Hage, A. Trento, J.A. Kobashigawa. CedarsSinai Heart Institute, Los Angeles, CA. Purpose: The assessment of the QT interval in brain death donors is important to exclude long QT syndrome, which may have been the cause of the death. Many heart transplant programs will have concern if a donor heart has a corrected QT (QTc)> 500 msec. Central nervous system abnormalities such as subarachnoid bleed might also lead to prolonged QT interval. Explosive brain death in donors has been associated with poor outcome after heart transplantation. As a prolonged QTc may be linked to central nervous system catastrophies, it is not known whether prolonged QTc interval in the donor heart is an independent risk factor for poor outcome. Therefore, we sought to evaluate donors to assess the association of prolonged QTc interval > 500 msec to first year outcomes. Methods: Between 2010 and 2014, we assessed 257 donor hearts for QTc interval > 500msec. Post-transplant outcomes included 1-year survival, 1-year freedom from any treated rejection, 1-year freedom from CAV defined as stenosis ≥ 30%, and 1-year freedom from Non-Fatal Major Adverse Cardiac Events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter, defibrillator/pacemaker implant, stroke). Results: Patients with QTc interval > 500 msec had a significantly lower 1-year freedom from CAV development. There was no significant difference in other first year outcomes. A significant higher percentage of donors with QTc > 500 msec had a stroke or subarachnoid hemorrhage as initial cause of brain death. Multivariate analysis found that donor QTc > 500 msec was associated with a 6.2-fold increase risk to the development of CAV (p= 0.033, 95% CI 1.2-33.0) after adjusting for other known CAV risk factors. (See table) Conclusion: QTc > 500 msec in the donor heart appears to be an independent risk factor for the development of early CAV after heart transplantation. Further investigation into these findings is being pursued.
Endpoints 1-Year Survival 1-Year Freedom from CAV 1-Year Freedom from NF-MACE 1-Year Freedom from Any Treated Rejection Donor Cause of Death: Cerebrovascular Accident/Stroke Donor Cause of Death: Head Trauma
QTc > 500 msec (n= 32)
QTc < 500 msec (n= 225)
P-Value
82.6% 85.7% 96.9%
91.1% 96.2% 88.4%
0.220 0.013 0.194
81.7%
83.6%
0.901
46.9% (15/32)
21.8% (49/225)
0.004
36.4% (8/32)
49.3% (111/225)
0.013
1( 41) Impact of Cytomegalovirus on Survival after Heart Transplant: Analysis of 20,000 Patients from the UNOS Registry Data G. Ashrith , A. Daoud, L.D. Teeter, J. Amione-Guerra, A.M. Cordero-Reyes, E. Graviss, B.H. Trachtenberg, A. Bhimaraj, A. Gaber, S. Scheinin,
G. Torre-Amione, J.D. Estep. Cardiology, Houston Methodist Hospital, Houston, TX. Purpose: Cytomegalovirus (CMV) infection has been implicated in a number of complications after heart transplant. Our study aim was to determine the effects of CMV donor-recipient status in a large cohort of patients undergoing heart transplant. Methods: All adult heart transplants from 2000 to 2012 were identified using the United Network for Organ Sharing (UNOS) database. Patients were grouped accordingly to donor and recipient CMV status: Donor+/Recipient+ (D+/R+), Donor+/Recipient- (D+/R-), Donor-/Recipient- (D-/R-) and Donor-/Recipient+ (D-/R+). We further analyzed HLA mismatch and outcomes in these four groups. Kaplan-Meir survival curves were analyzed for 10-year survival. Cox proportional hazard models were performed to determine predictors of mortality. P-values< 0.05 were considered significant. Results: A total of 20,783 patients receiving a heart transplant were analyzed, 75% were male, 72% Caucasian and 42% had ischemic cardiomyopathy. Of the total cohort, 7,963 (38%) were D+/R+, 4,839 (24%) D+/R-, 4,847 (23%) D-/R+ and 3,134 (15%) D-/R-. Ten year censored survival estimates differed significantly (p< 0.05) between all donor/recipient CMV status groups with the exception of D+/R+ vs. D+/R- (p= 0.372) and D-/ R+ vs. D-/R- (p= 0.062; figure A). When compared to D-/R- patients, the group with the greatest hazard for mortality was the D+/R+ (HR= 1.24 95%CI:1.1 -1.3; p-value< 0.01) followed by the D+/R- (HR= 1.20 95%CI: 1.1-1.3; p-value< 0.01). In the D+/R+ group the presence of ≥ 5 HLA mismatches further increased mortality while it had no effect on the other groups (p-value< 0.01, figure B). Conclusion: Our analysis has demonstrated that in a large cohort of patients, CMV positive donor status is associated with worse outcomes, independent of CMV status of the recipient. In those with CMV D+/R+ status having a ≥ 5 HLA mismatches significantly increases mortality.
1( 42) Stress Cardiomyopathy in Donor Hearts Does Not Affect the Outcome after Heart Transplantation T. Pintar ,1 G. Poglajen,2 R. Okrajšek,2 J. Kšela,3 I. Kneževič,3 B. Vrtovec.2 1Dept. of Anesthesiology and Intensive Therapy, UMC Ljubljana, Ljubljana, Slovenia; 2Advanced Heart Failure and Transplantation Programme, Dept. of Cardiology, UMC Ljubljana, Ljubljana, Slovenia; 3Dept. of Cardiovascular Surgery, UMC Ljubljana, Ljubljana, Slovenia.
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
of delisting for clinical worsening in the CF-LVAD cohort was 0.171 per patient year compared to 0.087 per patient year (p< 0.001). The incidence of VAD implantation in patients primarily medically bridged to transplantation was 0.217 per patient year. Two year survival after listing was lower in the CF-LVAD cohort (79.38 % vs 89.01; p< 0.001). Conclusion: We here present competing outcomes for heart transplant candidates bridged with and without VAD to transplantation after time of listing for heart transplantation. The overall outcomes including post-transplant survival were lower in the CF-LVAD cohort. The incidence for delisting from the waiting due to clinical worsening was higher in the CF-LVAD cohort. However, it needs to be emphasized that these are registry data, but prospective studies might help to best inform heart transplant candidates in their overall chance for survival after time they get listed. 1( 40) Prolonged Corrected QT Interval in the Donor Heart: Is There a Risk? J. Patel , M. Kittleson, L. Czer, T. Aintablian, D. Phan, D. Leong, J. Rush, E. Stimpson, D. Chang, A. Hage, A. Trento, J.A. Kobashigawa. CedarsSinai Heart Institute, Los Angeles, CA. Purpose: The assessment of the QT interval in brain death donors is important to exclude long QT syndrome, which may have been the cause of the death. Many heart transplant programs will have concern if a donor heart has a corrected QT (QTc)> 500 msec. Central nervous system abnormalities such as subarachnoid bleed might also lead to prolonged QT interval. Explosive brain death in donors has been associated with poor outcome after heart transplantation. As a prolonged QTc may be linked to central nervous system catastrophies, it is not known whether prolonged QTc interval in the donor heart is an independent risk factor for poor outcome. Therefore, we sought to evaluate donors to assess the association of prolonged QTc interval > 500 msec to first year outcomes. Methods: Between 2010 and 2014, we assessed 257 donor hearts for QTc interval > 500msec. Post-transplant outcomes included 1-year survival, 1-year freedom from any treated rejection, 1-year freedom from CAV defined as stenosis ≥ 30%, and 1-year freedom from Non-Fatal Major Adverse Cardiac Events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter, defibrillator/pacemaker implant, stroke). Results: Patients with QTc interval > 500 msec had a significantly lower 1-year freedom from CAV development. There was no significant difference in other first year outcomes. A significant higher percentage of donors with QTc > 500 msec had a stroke or subarachnoid hemorrhage as initial cause of brain death. Multivariate analysis found that donor QTc > 500 msec was associated with a 6.2-fold increase risk to the development of CAV (p= 0.033, 95% CI 1.2-33.0) after adjusting for other known CAV risk factors. (See table) Conclusion: QTc > 500 msec in the donor heart appears to be an independent risk factor for the development of early CAV after heart transplantation. Further investigation into these findings is being pursued.
Endpoints 1-Year Survival 1-Year Freedom from CAV 1-Year Freedom from NF-MACE 1-Year Freedom from Any Treated Rejection Donor Cause of Death: Cerebrovascular Accident/Stroke Donor Cause of Death: Head Trauma
QTc > 500 msec (n= 32)
QTc < 500 msec (n= 225)
P-Value
82.6% 85.7% 96.9%
91.1% 96.2% 88.4%
0.220 0.013 0.194
81.7%
83.6%
0.901
46.9% (15/32)
21.8% (49/225)
0.004
36.4% (8/32)
49.3% (111/225)
0.013
1( 41) Impact of Cytomegalovirus on Survival after Heart Transplant: Analysis of 20,000 Patients from the UNOS Registry Data G. Ashrith , A. Daoud, L.D. Teeter, J. Amione-Guerra, A.M. Cordero-Reyes, E. Graviss, B.H. Trachtenberg, A. Bhimaraj, A. Gaber, S. Scheinin,
G. Torre-Amione, J.D. Estep. Cardiology, Houston Methodist Hospital, Houston, TX. Purpose: Cytomegalovirus (CMV) infection has been implicated in a number of complications after heart transplant. Our study aim was to determine the effects of CMV donor-recipient status in a large cohort of patients undergoing heart transplant. Methods: All adult heart transplants from 2000 to 2012 were identified using the United Network for Organ Sharing (UNOS) database. Patients were grouped accordingly to donor and recipient CMV status: Donor+/Recipient+ (D+/R+), Donor+/Recipient- (D+/R-), Donor-/Recipient- (D-/R-) and Donor-/Recipient+ (D-/R+). We further analyzed HLA mismatch and outcomes in these four groups. Kaplan-Meir survival curves were analyzed for 10-year survival. Cox proportional hazard models were performed to determine predictors of mortality. P-values< 0.05 were considered significant. Results: A total of 20,783 patients receiving a heart transplant were analyzed, 75% were male, 72% Caucasian and 42% had ischemic cardiomyopathy. Of the total cohort, 7,963 (38%) were D+/R+, 4,839 (24%) D+/R-, 4,847 (23%) D-/R+ and 3,134 (15%) D-/R-. Ten year censored survival estimates differed significantly (p< 0.05) between all donor/recipient CMV status groups with the exception of D+/R+ vs. D+/R- (p= 0.372) and D-/ R+ vs. D-/R- (p= 0.062; figure A). When compared to D-/R- patients, the group with the greatest hazard for mortality was the D+/R+ (HR= 1.24 95%CI:1.1 -1.3; p-value< 0.01) followed by the D+/R- (HR= 1.20 95%CI: 1.1-1.3; p-value< 0.01). In the D+/R+ group the presence of ≥ 5 HLA mismatches further increased mortality while it had no effect on the other groups (p-value< 0.01, figure B). Conclusion: Our analysis has demonstrated that in a large cohort of patients, CMV positive donor status is associated with worse outcomes, independent of CMV status of the recipient. In those with CMV D+/R+ status having a ≥ 5 HLA mismatches significantly increases mortality.
1( 42) Stress Cardiomyopathy in Donor Hearts Does Not Affect the Outcome after Heart Transplantation T. Pintar ,1 G. Poglajen,2 R. Okrajšek,2 J. Kšela,3 I. Kneževič,3 B. Vrtovec.2 1Dept. of Anesthesiology and Intensive Therapy, UMC Ljubljana, Ljubljana, Slovenia; 2Advanced Heart Failure and Transplantation Programme, Dept. of Cardiology, UMC Ljubljana, Ljubljana, Slovenia; 3Dept. of Cardiovascular Surgery, UMC Ljubljana, Ljubljana, Slovenia.