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110: Outcomes after Heart Transplantation for Chemotherapy-Induced Cardiomyopathy: Results from a Multi-Center Registry
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The Journal of Heart and Lung Transplantation, Vol 29, No 2S, February 2010
the best of our knowledge, its usefulness for predicting outcomes after urgent heart transplantation has not been explored yet. Methods and Materials: We studied 88 consecutive patients (14 women, mean age 49.7 years) who underwent urgent heart transplantation (HT) at our centre since 1991 to 2006. They were divided in two groups. Group A (n⫽67) included 25 patients at the INTERMACS 3 level (“stable on inotropics”) and 42 patients at the INTERMACS 2 level (“sliding on inotropics”). Group B included 21 patients at the INTERMACS 1 level (“critical cardiogenic shock”). No patient at INTERMACS 4-7 levels underwent urgent heart transplantation. Pretrasplant clinical characteristics and postoperative outcomes were compared. Results: Before HT, Group B patients more frequently had an IABP/ LVAD (95.2% vs 59.7%, p⫽0.002) and mechanical ventilation (85.7% vs 40.3%, p⬍0.001) than group A patients. Preoperative infection was also more frequent in group B (57.1% vs 33.3%, p⫽0.05). Group B showed higher preoperative ejection fraction (0.31⫾0.19 vs 0.22⫾0.1, p⫽0.01), mean pulmonary arterial pressure (41.4⫾14.4 vs 34.1⫾9.2 mm Hg, p⫽0.049), plasmatic AST (1340⫾2905 vs 203⫾405 UI/l, p⫽0.01) and plasmatic ALT (1182⫾2280 vs 298⫾911 U/l, p⫽0.02); and lower creatinin clearance (54.3⫾27.5 vs 74.0⫾34.6 mg/ml, p⫽0.02). Mean cold ischemia time was higher in group B (221.1⫾65.2 vs 181.8⫾76.1 min, p⫽0.03). After HT, Group B showed higher rates of primary graft failure (33.3% vs 13.4%, p⫽0.04) and need for postoperative renal replacement therapy (47.6% vs 18.1%, p⫽0.007). In-hospital mortality was 52.4% in group B and 13.4% in group A (p⬍0.001, adjusted OR 9.2, IC95% 2.0-42.9). Conclusions: Our data suggest that the INTERMACS classification may be a useful tool for risk stratification and outcome prediction in critically ill patients awaiting urgent heart transplantation. 109 Improvement in Heart Transplant Survival Across Eras: Have All Racial Groups Benefited Equally? Race-Era Interaction in a RiskAdjusted Model T.P. Singh, C.S. Almond, G. Piercey, K. Gauvreau. Children’s Hospital Boston, Boston, MA. Purpose: The purpose of this study was to assess whether the improvement in post-transplant survival in heart transplant (HT) recipients during the last 2 decades has benefited the major racial groups in the United States (US) equally. Methods and Materials: We analyzed all primary HT recipients ⱖ18 years of age in the US between 1987 and 2008 using the Organ Procurement and Transplant Network data. We compared baseline characteristics and time to graft loss (death or re-transplant) in white, black and Hispanic recipients in 5 successive HT cohorts (1987-92, 93-96, 97-00, 01-04, 05-08) using Cox regression models. Results: There were 29,986 white, 4,745 black and 2,017 Hispanic HT recipients in the study cohort. The proportion of black and Hispanic recipients increased whereas the proportion of white recipients decreased over 2 decades (P⬍0.001 for trend). Black recipients were more likely to have dilated cardiomyopathy compared to white and Hispanic recipients in all eras (P⬍0.001). The proportion of patients on a ventricular assist device prior to HT increased with time in all three groups (P⬍0.001 for trend). In multivariable analysis, there was no race-era interaction for early (6-mo) post-HT survival (P⫽ 0.78 and 0.71 for interaction) which improved in all racial groups with time (hazard ratio, HR 0.85, 95% CI 0.82, 0.89 for successive eras, P⬍0.001). Longer-term survival in those who survived the first 6-mo post-HT (conditional survival) was worse in black HT recipients (adjusted HR 1.61, CI 1.52, 1.69, P⬍0.001) and improved with time in white (adjusted HR 0.94, CI 0.91, 0.97 for successive eras, P⬍0.001) but not in black (HR 1.05, CI 0.98, 1.12, P⫽0.18) or Hispanic (HR 1.04, CI 0.92, 1.17, P⫽0.51) recipients. Conclusions: The improvement in early (6-mo) post-HT survival during the last 2 decades has benefited white, black and Hispanic recipients equally. Longer-term survival has improved in white but not in black or Hispanic recipients. The reasons for this disparity in outcomes warrant further investigation.
110 Outcomes after Heart Transplantation for Chemotherapy-Induced Cardiomyopathy: Results from a Multi-Center Registry B.W. Hardaway,1 A.Y. Kucheryavaya,2 L.B. Edwards,2 J. Stehlik,3 D.O. Taylor.1 1Cleveland Clinic, Cleveland, OH; 2United Network for Organ Sharing, Richmond, VA; 3University of Utah, Salt Lake City, UT. Purpose: Chemotherapy-induced cardiomyopathy (ChemoCM) is an unfortunate complication of cancer therapy. Often patients progress to endstage heart failure and may be considered for heart transplantation (OHT). OHT in this population has been limited due to concerns about the potential adverse post-transplant effects of prior chemotherapy and risk of recurrent or new malignancies. Our aim was to examine post-transplant outcomes among patients with ChemoCM and non-ischemic cardiomyopathies (NICM) who have undergone OHT. Methods and Materials: The International Society of Heart and Lung Transplantation (ISHLT) database was queried and 231 ChemoCM pts transplanted between 01/2000 – 12/2008 were compared to a reference group of 8794 NICM OHT pts. Demographic and categorical outcomes were compared using Chi-square or Fisher’s exact test. Survival was compared using Kaplan-Meier method. Results: Immunosuppressive regimens were similar between the two groups. Demographics, incidences of infection, rejection and malignancy are shown in Table 1. Gender differences were due to high incidence of prior breast cancer in ChemoCM. While there was a trend toward greater number of malignancies in ChemoCM group, the absolute numbers were small.[table1]One- and five-year survival rates were similar between pts with ChemoCM and NICM: 85% vs.87% and 71% vs. 74%, respectively; p⫽ 0.25. Conclusions: These data suggest that OHT is feasible in patients with ChemoCM with similar mortality and rejection risks. However, the higher rate of post-transplant infection and, possibly malignancy, stresses the importance of careful patient selection and subsequent post-transplant management.
Demographic and post-transplant morbidity ChemoCM (n⫽231) Recipient/donor age (yrs) Gender: M/F (n) Hospitalized for infection Hospitalized for rejection Treated for rejection during year 1 Post-transplant malignancy ⴱ
p⬍0.001;
ⴱⴱ
p⫽0.0065;
ⴱⴱⴱ
ⴱ
48.0 /28.0 82/149ⴱ 28.1%ⴱⴱ 11.1% 20.8% 4.3%ⴱⴱⴱ
ⴱ
NICM (n⫽8794) 52.0ⴱ/32.0ⴱ 6613/218ⴱ 18.8% ⴱⴱ 12.8% 25.0% 1.9%ⴱⴱⴱ
p⫽0.052
111 Safety and Outcomes with Newer Treatment Strategies for Cardiac Antibody-Mediated Rejection: Still in the Woods D. Budge, F. Khan, M.E.H. Hammond, Z.D. Nilson, J. Stehlik, R. Alharethi, M.D. Everitt, E.M. Gilbert, F. Bader, D.V. Miller, P. Revelo, S.G. Drakos, A.G. Kfoury. UTAH Cardiac Transplant Program, Salt Lake City, UT. Purpose: Despite increased awareness about the significance of cardiac antibody-mediated rejection (AMR), a standardized treatment approach remains to be defined. Newer strategies that incorporate targeting the production of antibodies are promising but little is reported on their safety and longer-term outcomes. In this study, we reviewed our experience with the use of rituximab in a larger group of heart transplant (Tx) recipients with AMR. Methods and Materials: The UTAH Cardiac Transplant Program database was queried for patients who received rituximab for the indication of AMR with hemodynamic compromise (HC) (LVEF ⱕ 0.40, use of inotropes, and/or heart failure symptoms) and/or AMR with accelerated cardiac allograft vasculopathy (CAV). Outcomes of interest included tolerability and safety of rituximab, resolution and recurrence of AMR, hospital discharge and survival.
The Journal of Heart and Lung Transplantation, Vol 29, No 2S, February 2010
the best of our knowledge, its usefulness for predicting outcomes after urgent heart transplantation has not been explored yet. Methods and Materials: We studied 88 consecutive patients (14 women, mean age 49.7 years) who underwent urgent heart transplantation (HT) at our centre since 1991 to 2006. They were divided in two groups. Group A (n⫽67) included 25 patients at the INTERMACS 3 level (“stable on inotropics”) and 42 patients at the INTERMACS 2 level (“sliding on inotropics”). Group B included 21 patients at the INTERMACS 1 level (“critical cardiogenic shock”). No patient at INTERMACS 4-7 levels underwent urgent heart transplantation. Pretrasplant clinical characteristics and postoperative outcomes were compared. Results: Before HT, Group B patients more frequently had an IABP/ LVAD (95.2% vs 59.7%, p⫽0.002) and mechanical ventilation (85.7% vs 40.3%, p⬍0.001) than group A patients. Preoperative infection was also more frequent in group B (57.1% vs 33.3%, p⫽0.05). Group B showed higher preoperative ejection fraction (0.31⫾0.19 vs 0.22⫾0.1, p⫽0.01), mean pulmonary arterial pressure (41.4⫾14.4 vs 34.1⫾9.2 mm Hg, p⫽0.049), plasmatic AST (1340⫾2905 vs 203⫾405 UI/l, p⫽0.01) and plasmatic ALT (1182⫾2280 vs 298⫾911 U/l, p⫽0.02); and lower creatinin clearance (54.3⫾27.5 vs 74.0⫾34.6 mg/ml, p⫽0.02). Mean cold ischemia time was higher in group B (221.1⫾65.2 vs 181.8⫾76.1 min, p⫽0.03). After HT, Group B showed higher rates of primary graft failure (33.3% vs 13.4%, p⫽0.04) and need for postoperative renal replacement therapy (47.6% vs 18.1%, p⫽0.007). In-hospital mortality was 52.4% in group B and 13.4% in group A (p⬍0.001, adjusted OR 9.2, IC95% 2.0-42.9). Conclusions: Our data suggest that the INTERMACS classification may be a useful tool for risk stratification and outcome prediction in critically ill patients awaiting urgent heart transplantation. 109 Improvement in Heart Transplant Survival Across Eras: Have All Racial Groups Benefited Equally? Race-Era Interaction in a RiskAdjusted Model T.P. Singh, C.S. Almond, G. Piercey, K. Gauvreau. Children’s Hospital Boston, Boston, MA. Purpose: The purpose of this study was to assess whether the improvement in post-transplant survival in heart transplant (HT) recipients during the last 2 decades has benefited the major racial groups in the United States (US) equally. Methods and Materials: We analyzed all primary HT recipients ⱖ18 years of age in the US between 1987 and 2008 using the Organ Procurement and Transplant Network data. We compared baseline characteristics and time to graft loss (death or re-transplant) in white, black and Hispanic recipients in 5 successive HT cohorts (1987-92, 93-96, 97-00, 01-04, 05-08) using Cox regression models. Results: There were 29,986 white, 4,745 black and 2,017 Hispanic HT recipients in the study cohort. The proportion of black and Hispanic recipients increased whereas the proportion of white recipients decreased over 2 decades (P⬍0.001 for trend). Black recipients were more likely to have dilated cardiomyopathy compared to white and Hispanic recipients in all eras (P⬍0.001). The proportion of patients on a ventricular assist device prior to HT increased with time in all three groups (P⬍0.001 for trend). In multivariable analysis, there was no race-era interaction for early (6-mo) post-HT survival (P⫽ 0.78 and 0.71 for interaction) which improved in all racial groups with time (hazard ratio, HR 0.85, 95% CI 0.82, 0.89 for successive eras, P⬍0.001). Longer-term survival in those who survived the first 6-mo post-HT (conditional survival) was worse in black HT recipients (adjusted HR 1.61, CI 1.52, 1.69, P⬍0.001) and improved with time in white (adjusted HR 0.94, CI 0.91, 0.97 for successive eras, P⬍0.001) but not in black (HR 1.05, CI 0.98, 1.12, P⫽0.18) or Hispanic (HR 1.04, CI 0.92, 1.17, P⫽0.51) recipients. Conclusions: The improvement in early (6-mo) post-HT survival during the last 2 decades has benefited white, black and Hispanic recipients equally. Longer-term survival has improved in white but not in black or Hispanic recipients. The reasons for this disparity in outcomes warrant further investigation.
110 Outcomes after Heart Transplantation for Chemotherapy-Induced Cardiomyopathy: Results from a Multi-Center Registry B.W. Hardaway,1 A.Y. Kucheryavaya,2 L.B. Edwards,2 J. Stehlik,3 D.O. Taylor.1 1Cleveland Clinic, Cleveland, OH; 2United Network for Organ Sharing, Richmond, VA; 3University of Utah, Salt Lake City, UT. Purpose: Chemotherapy-induced cardiomyopathy (ChemoCM) is an unfortunate complication of cancer therapy. Often patients progress to endstage heart failure and may be considered for heart transplantation (OHT). OHT in this population has been limited due to concerns about the potential adverse post-transplant effects of prior chemotherapy and risk of recurrent or new malignancies. Our aim was to examine post-transplant outcomes among patients with ChemoCM and non-ischemic cardiomyopathies (NICM) who have undergone OHT. Methods and Materials: The International Society of Heart and Lung Transplantation (ISHLT) database was queried and 231 ChemoCM pts transplanted between 01/2000 – 12/2008 were compared to a reference group of 8794 NICM OHT pts. Demographic and categorical outcomes were compared using Chi-square or Fisher’s exact test. Survival was compared using Kaplan-Meier method. Results: Immunosuppressive regimens were similar between the two groups. Demographics, incidences of infection, rejection and malignancy are shown in Table 1. Gender differences were due to high incidence of prior breast cancer in ChemoCM. While there was a trend toward greater number of malignancies in ChemoCM group, the absolute numbers were small.[table1]One- and five-year survival rates were similar between pts with ChemoCM and NICM: 85% vs.87% and 71% vs. 74%, respectively; p⫽ 0.25. Conclusions: These data suggest that OHT is feasible in patients with ChemoCM with similar mortality and rejection risks. However, the higher rate of post-transplant infection and, possibly malignancy, stresses the importance of careful patient selection and subsequent post-transplant management.
Demographic and post-transplant morbidity ChemoCM (n⫽231) Recipient/donor age (yrs) Gender: M/F (n) Hospitalized for infection Hospitalized for rejection Treated for rejection during year 1 Post-transplant malignancy ⴱ
p⬍0.001;
ⴱⴱ
p⫽0.0065;
ⴱⴱⴱ
ⴱ
48.0 /28.0 82/149ⴱ 28.1%ⴱⴱ 11.1% 20.8% 4.3%ⴱⴱⴱ
ⴱ
NICM (n⫽8794) 52.0ⴱ/32.0ⴱ 6613/218ⴱ 18.8% ⴱⴱ 12.8% 25.0% 1.9%ⴱⴱⴱ
p⫽0.052
111 Safety and Outcomes with Newer Treatment Strategies for Cardiac Antibody-Mediated Rejection: Still in the Woods D. Budge, F. Khan, M.E.H. Hammond, Z.D. Nilson, J. Stehlik, R. Alharethi, M.D. Everitt, E.M. Gilbert, F. Bader, D.V. Miller, P. Revelo, S.G. Drakos, A.G. Kfoury. UTAH Cardiac Transplant Program, Salt Lake City, UT. Purpose: Despite increased awareness about the significance of cardiac antibody-mediated rejection (AMR), a standardized treatment approach remains to be defined. Newer strategies that incorporate targeting the production of antibodies are promising but little is reported on their safety and longer-term outcomes. In this study, we reviewed our experience with the use of rituximab in a larger group of heart transplant (Tx) recipients with AMR. Methods and Materials: The UTAH Cardiac Transplant Program database was queried for patients who received rituximab for the indication of AMR with hemodynamic compromise (HC) (LVEF ⱕ 0.40, use of inotropes, and/or heart failure symptoms) and/or AMR with accelerated cardiac allograft vasculopathy (CAV). Outcomes of interest included tolerability and safety of rituximab, resolution and recurrence of AMR, hospital discharge and survival.