11 Advanced Heart Failure Requiring Emergency Surgical Therapy: Emergency Heart Transplantation with Marginal Donors vs. LVAD Implant

Abstracts porating post-transplant risk it could be considered as the basis for a new heart allocation policy in Eurotransplant.

9 Outcomes in Destination Therapy VAD and Extended Criteria Cardiac Transplantation Stratified by HeartMate Risk Score C.B. Patel, M.A. Daneshmand, A.A. Simeone, A.F. Hernandez, G.M. Felker, P.B. Rosenberg, L.J. Blue, C.A. Milano, J.G. Rogers. Duke University Medical Center, Durham, NC. Purpose: Destination therapy left ventricular assist device (DTVAD) and extended-criteria cardiac transplantation (ECCT) are therapies for patients (pts) with end-stage heart failure (HF) and advanced age/comorbid conditions. DTVAD and ECCT have not been compared on the basis of perioperative risk. We evaluated outcomes of pts treated with ECCT or DTVAD at our center stratified by HeartMate Risk Score (HMRS). Methods and Materials: 111 consecutive pts treated with DTVAD (n⫽69, continuous flow VAD) or ECCT (n⫽42) between 2005-2010 were retrospectively evaluated. Pts were assigned to low-intermediate (int) or highrisk groups based on preoperative HMRS. Survival analysis was performed before and after stratification by HMRS (median follow up 483 days). Results: Mean age (67y), sex and heart failure etiology were similar in both groups. DTVAD pts had lower EF (15% vs 20%, p⫽0.01) and lower cardiac index(1.8 L/min/m2 vs 2.1 L/min/m2, p⫽0.01). Overall, there was a trend towards higher 2-year survival with ECCT than DTVAD (75% vs 70%, p⫽0.06), due to increased perioperative mortality with DTVAD. When stratified by HMRS, survival was identical for pts with low-int risk (74% vs 76%, p⫽ 0.983, figure). Increased mortality with DTVAD compared with ECCT was seen in high-risk HMRS groups (figure).

S13 B. Bruckner,1 S. Scheinin,1 B. Ramlawi,1 G. Torre-Amione.1,2 1The Methodist DeBakey Heart & Vascular Center, The Methodist Hospital, Houston, TX; 2Cardiology, Hospital San Jose Tec de Monterrey, Monterrey, NL, Mexico. Purpose: Patients with end stage heart failure (HF) awaiting heart transplantation (txp) benefit from ambulation. The use of trans-thoracic IABP placement has not been well documented. This study reports our feasibility and safety in 35 patients with advanced HF deemed high risk for LVAD placement undergoing percutaneously placed axillary-subclavian IABP as a bridge to heart txp and heart multi-organ txp. Methods and Materials: We developed a percutaneous technique to place 7.5F IABPs in the descending thoracic aorta via direct left axillary artery puncture and retrospecitively reviewed these patients being bridged to txp from July 2007 to Sept. 2011. Results: 30/35 (86%) patients were successfully bridged to txp (3 expired from multi organ failure, 1 required high risk LVAD and 1 required a total artificial heart [Figure 1A]. 26/30 patients received heart only txp, 2/29 heart-kidney txp, 1/29 heart-liver txp, and 1/29 heart-double lung. No early post IABP complications noted. Major adverse events with prolonged support included left axillary artery thrombus requiring percutaneous thrombectomy in 2 patients, thrombus formation requiring brachial artery embolectomy in 2 patients, hematoma formation after IABP removal and Angioseal closure requiring evacuation in 1 patients [Figure 1B]. Minor adverse events: kinking, IABP rupture, or minor bleeding around sheath site requiring IABP removal or exchange occurred in 11 patients.

Conclusions: Prolonged axillary IABP support is an effective strategy as a bridge to heart and multi-organ transplantation in end stage heart failure patients and is associated with a manageable and acceptable adverse event profile. 11 Advanced Heart Failure Requiring Emergency Surgical Therapy: Emergency Heart Transplantation with Marginal Donors vs. LVAD Implant A. Forni, B. Chiominto, A. Mazzucco, G. Faggian. Cardiac Surgery, University Hospital of Verona, Verona, Italy.

Conclusions: In our experience, both DTVAD and ECCT provide survival rates of ⬃70 % at 2 years. Survival is identical in low-int risk pts but lower with DTVAD therapy in the high-risk category. Given the components of the score, the high risk HMRS group may identify pts with biventricular failure who benefit from ECCT. If validated in other cohorts, DTVAD and ECCT should be considered comparable therapies for select pts with end-stage HF. 10 Successful Use of Percutaneously Placed Axillary-Subclavian IntraAortic Balloon Pumps That Permit Ambulation as a Bridge to Heart and Multi-Organ Transplantation J.D. Estep,1 A.M. Cordero-Reyes,1 A. Bhimaraj,1 M. Loebe,1

Purpose: Discrepancy between reduced donor pool and increased number of patients affected by end stage heart disease lead us the review our experience. Comparison was made between patients undergone to emergency HTx with organs from marginal donors and patients who had LVAD as bridge to decision. Methods and Materials: Among 77 patients undergone to HTX between October 2008 and October 2011, 35 (46%) (male, 77%, female 23%, aged 20 to 70 years, mean, 47 years., affected by dilated cardiomyopathy, 45% or other, 55%; on NYHA class IV, 100%) had organs from marginal donors (14 HCV positive, 7 affected by coronary diseases, 14 with ECHO anomalies). Ten patients (male:100%, aged 31 to 70 years, mean, 48 years, affected by dilated cardiomyopathy, 40% or other, 60%; on NYHA class IV, 100%) underwent to LVAD Heart Mate II type implant. Parameters considered were: m. pump flow: 5,2 l/min; m. pump speed: 9000rpm, range: 8900-9400 rpm. INR was kept between 1,8 and 2,3.

S14

The Journal of Heart and Lung Transplantation, Vol 31, No 4S, April 2012

Results: Results are summarized on table 1. Group1 : 35 pts. undergone to emergency HTx using organs retrieved from marginal donors

Variable 30 days actuarial survival rate 36 months actuarial survival rate mean in hospital stay 12 months acute rejection freedom 36 months infection freedom 36 months infection donor related freedom 36 months chronic rejection freedom 36 months cerebral haemmorage freedom hospital readmission ep./pt./year out patient clinic admission ep./ pt.year patient number undergone to HTx patient number on HTX waiting list

91% 87% 24 36% 41% 75%

⫾ ⫾ ⫾ ⫾ ⫾ ⫾

1 2 4 days 5 2 1

and had inferior 1 year survival compared with Tx/VAD.Survival on palliative milrinone is generally ⬍ 6 months and is far inferior to Tx/VAD but did have improved NYHA functional class. Group 2: 10 pts. undergone to HM II implant as bridge to decision 90% 80% 28 — 30% —

13

⫾ 1 ⫾ 1 ⫾ 1 days ⫾ 2

p.v.

WITHDRAWN

n.s. n.s. n.s. — n.s. —

14

69% ⫾ 2

—

—

100%

80% ⫾ 1

n.s.

3.1⫾ 13 ⫾ 3

n.s. n.s.

2.1 ⫾ 1 14 ⫾ 2 —

4 4

Conclusions: Results of our brief report seems to indicate that MCS used as bridge to decision in emergency conditions is yield to an excellent clinical outcome in terms of survival rate and of infection occurrence. Further experience is needed. 12 Outcomes with Use of Continuous Outpatient Milrinone Infusions in Patients with Advanced Heart Failure (AHF) P. Muthusamy,1,2 S. Madan,3 K. Mowers,3 D.E. Langholz,1 J.D. Call,1 M.B. Hanrahan,4 A.T. Davis,2,3 H. Pahwa,2 M.G. Dickinson.1 1 Cardiology, Fredrik Meijer Heart & Vascular Institute/Spectrum Health, Grand Rapids, MI; 2Grand Rapids Medical Education Partners, Grand Rapids, MI; 3Michigan State University/College of Human Medcine, Grand Rapids, MI; 4Coram Home Infusion Group, Grand Rapids, MI. Purpose: Assess outcomes on inotrope dependent (ID) AHF patients treated with continuous home infusion milrinone (HIM). Methods and Materials: Retrospective analysis of all ID patients discharged with continuous HIM support from January 2008 to October 2010.Outcomes were assessed for 3 groups:(Group 1) milrinone as a bridge to transplant or left ventricular assist device(Tx/VAD),(Group 2) milrinone weaning strategy(to improve clinical stability then empiric weaning) and (Group 3) palliative end stage strategy.ID was defined as cardiac index ⬍ 2 liters/min/m2 with signs or symptoms of end organ dysfunction despite maximal vasodilation and with improvement in hemodynamics and symptoms on milrinone infusion. Results: 49 patients (Age 61.4⫾15 years; 41 males) were treated with continuous HIM. Data is summarized. Outcome analysis for HIM

Groups

Decription, n (%)

Median HIM support (days)

One year survival

Median survival NYHA (days) (baseline)

NYHA-3 months (Of those alive)

NYHA-6 months (Of those alive)

Group 1

Bridge to Tx/VAD, 18 (36.7%)

98 (18-212)

83.3%

662 (44-1206)

3.89

2

2

Group 2

Weaned, 13 (26.5%)

109 (31-218)

73.4%

408 (242-967)

3.92

2

2

Group 3

Palliative, 18 (36.7%)

146 (4-525)

11.1%

163 (14-525)

3.76

3

3

Only 1 patient in group 1 died while on milrinone support and this was during a procedure while hospitalized prior to transplant.13 patients were able to be weaned from milrinone but had inferior survival to Tx/VAD group.Palliative HIM was associated with 5.4 months median survival.All groups had improvement in mean New York Heart Association (NYHA) functional class. Conclusions: Continuous outpatient milrinone was safely used as a temporary bridge to definitive therapy (Tx/VAD) with a 3.3 month median duration of support.Approximately one-fourth of the ID patients were successfully weaned from milrinone but these patients remained high risk

Administration of Antibodies to Self Antigens (K␣1 Tubulin and Collagen V) Results in Obliterative Bronchitis after Syngeneic Mouse Lung Transplantation V. Subramanian,1 M. Takenaka,1 V. Tiriveedhi,1 N. Benshoff,1 S. Yamamoto,1 A.E. Gelman,1 A. Patterson,1 T. Mohanakumar.1,2 1 Surgery, Washington University, St. Louis, MO; 2Pathology and Immunology, Washington University, St. Louis, MO. Purpose: Background: Immune responses against mismatched MHC and self-antigens(Ag) [K␣1tubulin (K␣1T)and Collagen V (ColV)] are postulated in immunopathogenesis of chronic rejection after human lung transplantation. The goal of this study was to determine the role of antibodies (Abs) to self-antigens in the absence of immune responses to MHC in the induction of chronic rejection [Obliterative Bronchitis (OB)] in a murine model of syngeneic left lung transplantation (LT). Methods and Materials: Syngeneic LT was performed in C57Bl/6 mice. Endotoxin free Abs to ColV and K␣1T (Group 1 n⫽5 - 200␮g/dose, intraperitoneal) or Abs to K␣1T alone (Group 2 -n⫽5) were administered on days -10, -2, 0 & weekly thereafter following LT. Graft and native lungs were analyzed by H&E and trichrome stain. Sera were tested for Abs to K␣1T and ColV by ELISA. K␣1T and Col V specific IFN-␥, IL-10 and IL-17 cells were enumerated by ELISpot. Results: Syngeneic LT had normal function with no rejection. Administration of Abs to K␣1T and ColV or K␣1T alone resulted in OB evidenced by cellular infiltration around bronchioles and vessels, epithelial metaplasia and fibrosis by day 30 both in allograft and in native lung. Control LT did not develop OB. In both groups 1 & 2 there was significant increase in cells secreting IFN␥ and IL-17 to ColV and K␣1T (spots per million cells for IFN␥ and IL-17 – ColV - 80⫾12, 15⫾4, p⬍0.05; K␣1T 79⫾15, 20⫾5, p⬍0.05, Group 2 – ColV 89⫾13, 26⫾8; K␣1T - 100⫾17, 20⫾7, p⬍0.05). Conclusions: Administration of Abs to lung specific self-antigens resulted in OB both in allograft and native lungs in a murine syngeneic LT. Abs bound to self-Ags exposed following inflammation induced by transplantation results in induction and perpetuation of autoimmunity that results in OB not only in allograft but also in native lung. 15 The Pro-Inflammatory Cytokine IL-17 Acts Directly on Bronchiolar Epithelium – Implications for Chronic Lung Allograft Dysfunction Pathogenesis S.T. Yerkovich,1,2 M.E. Tan,1 K.A. Sinclair,1 A. Fiene,1 P.M. Hopkins,1,2 D.C. Chambers.1,2 1Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, Australia; 2School of Medicine, The University of Queensland, Brisbane, Australia. Purpose: Long term survival after lung transplantation is limited due to the development of chronic lung allograft dysfunction (CLAD). CLAD is associated with increased IL-17 production, which is thought to mediate neutrophil activation. We hypothesised that IL-17 may also contribute to CLAD pathogenesis by acting directly on the bronchiolar epithelium. Methods and Materials: Primary small airway epithelial cells were obtained from small airway brushings. Flow cytometry was used to quantify receptor expression (IL-17RA) directly ex vivo, and primary cell cultures were established. IL-8 was measured in bronchoalveolar lavage (BAL) by ELISA. Epithelial mesenchymal transition (EMT) was assessed following stimulation with IL-17 (1, 10, 100 ng/ml) alone or in combination with TGF␤ (10ng/ml). Results: Bronchiolar epithelial cells were found to express the receptor for IL-17 and expression was higher in patients with CLAD (15.6% (15.332.3; n⫽5) vs 7.3% (6.5-10.1; n⫽11); p⫽0.020). Increased IL-17 receptor expression was associated with increased BAL IL-8 (r⫽0.649, p⫽0.006), suggesting cross-regulation between IL-8, IL-17 and its receptor. In vitro,