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2: Outcomes Following Transplantation for Congenital Heart Disease in Adults
ABSTRACTS 1 Focusing on the Future: Development of a Predictive Model for Long-Term Survival C.J. Gries1, T.C. Rue2, P.J. Heagerty2, J. Edelman1, M.S. Mulligan3, C.H. Goss1 1University of Washington School of Medicine, Seattle, WA; 2University of Washington School of Medicine, Seattle, WA; 3 University of Washington School of Medicine, Seattle, WA Purpose: To develop and validate a predictive model of 5-year survival in lung transplant recipients in order to aid in quality improvement, adjust for case mix and improve counseling of patients prior to transplantation. Methods and Materials: Lung transplant recipients transplanted between 1997-2008 were identified in the ISHLT International Registry for Heart and Lung Transplantation. Exclusion criteria included: age⬍ 18 and re-transplantation. Multiple imputation was performed for variables to handle missing values. Two datasets of equal size were randomly generated: development and validation sets. Akaike Information Criterion was used to identify the best predictive model. Candidate variables included: age, gender, diagnosis, O2 requirements, FVC, FEV1, six minute walk test (6MWT), CO2, mechanical ventilation, pulmonary artery pressures, wedge pressure, cardiac output (CO), body mass index (BMI), creatinine (Cr), ABO blood type, diabetes, hypertension (HTN), malignancy, Epstein Barr Virus (EBV), hepatitis C virus (HCV), Cytomegalovirus (CMV), transfusions. Results: A total of 18,621 patients were identified. In the development sample, patient characteristics included: median (IQR) age of 54 (43, 60) years, 54% male, 36% Chronic Obstructive Pulmonary Disease (COPD), 22% Idiopathic Pulmonary Fibrosis (IPF), and 16% Cystic Fibrosis (CF). One- and 5-year survival estimates were 82% and 66% respectively. A preliminary model was generated: Five year 0.009*age survival(x)⫽0.186*diabetes ⫹ 0.059*O2⫹ 0.0002*6MWT ⫹ 0.148*Cr - 0.043*CO ⫹ 0.016*CF ⫹ 0.077*IPF 0.089*COPD - 0.116*EBV ⫹ 0.112*HTN ⫹ 0.184*transfusion history ⫹0.162*malignancy. The best model predictive model of 5-year survival will be presented along with its model diagnostics. Conclusions: A preliminary model of long term survival was developed. This model may be helpful for bench-marking, to adjust for case mix in research studies and to improve patient counseling prior to transplantation. 2 Outcomes Following Transplantation for Congenital Heart Disease in Adults R.R. Davies1, M.J. Russo1, J. Yang1, J.M. Quaegebeur1, R.S. Mosca1, J.M. Chen2 1Children’s Hospital of NewYork-Presbyterian, New York, NY; 2Weill Medical College of Cornell University, New York, NY Purpose: An increasing number of patients with congenital heart disease (CHD) are reaching adulthood, often with suboptimal cardiac function eventually leading to end-stage heart failure; the survival of these patients following transplantation (TXPL) has not been evaluated. Methods and Materials: A review of the UNOS database identified 21,095 adult heart TXPL recipients 1995-2005. Recipients were stratified into 3 groups: patients with a history of CHD (CHD, n ⫽ 411, 2.0%), patients without CHD (nCHD, n ⫽ 13,722, 66.3%) and those without CHD but with a previous sternotomy (nCHD-REOP, n ⫽ 6.962, 31.7%). Results: At the time of TXPL, patients in the CHD group were younger (34.6 yrs vs. 53.3 & 52.3, p⬍0.0001); most had a previous sternotomy (92.7%). While rates of hospitalization (53.4% vs. 52.4% & 62.0%, p⬍0.0001), ICU care (35.1% vs. 31.9% & 46.8%, p⬍0.0001),
mechanical ventilation (4.1% vs. 3.8% & 2.6%, p⬍0.0001) and inotropic support (46.2% vs. 42.9% & 55.2%, p⬍0.0001) were similar, they were much less likely to need mechanical circulatory support (MCS) at TXPL (7.5% vs 34.3% & 15.8%, p⬍0.0001). A higher proportion of CHD patients had body mass index less than 20 (31.1% vs. 10.9% & 16.9%, p⬍0.0001). Overall post-TXPL survival was significantly lower in the CHD group, mostly due to decreased 30-day survival (Figure). Logistic regression demonstrates the significant independent effect of CHD on 30-day mortality (odds ratio 2.7, 95%CI 2.3-4.6). Other important predictors are given in Figure. Conclusions: Adults with CHD have high 30-day mortality after heart TXPL despite being younger and requiring MCS less often. This may be due to a combination of highly complex reoperative surgery and often poor preoperative systemic health.
3 Does VAD Therapy as a “Bridge to Candidacy” Apply to the Morbidly Obese? J.W. Haft1, M.A. Romano1, J.C. Matthews2, D.B. Dyke2, F.D. Pagani1 1University of Michigan, Ann Arbor, MI; 2University of Michigan, Ann Arbor, MI Purpose: Morbid obesity is a relative contraindication for heart transplantation. While ventricular assist devices (VADs) have served as a “bridge to candidacy” in patients with renal insufficiency, pulmonary hypertension, and tobacco addiction, it is unclear if morbidly obese advanced heart failure patients will lose weight on mechanical circulatory support. Methods and Materials: We reviewed our prospectively collected database of implantable mechanical circulatory support from January, 2000 to September, 2008. Weights were recorded preoperatively and during outpatient follow up visits every three months. Patients were stratified into five weight classes: Body mass index (BMI) ⬍ 20, 20 to ⬍ 25, 25 to ⬍30, 30 to ⬍ 35, and ⱖ35. Survival was determined using the Kaplan Meier method, and multivariable analysis was performed using Cox regression. Results: Of the 222 patients receiving implantable circulatory support devices, 96 were supported for at least 6 months on an outpatient basis. Average weights for the entire cohort were 86.4, 84.8, 87.3, 89.8, and 90.2 kg at baseline, 3 months, 6 months, 9 months and 1 year, respectively. BMI was essentially unchanged for all weight classes over the study period (Figure 1). Although BMI was not an independent predictor of VAD mortality, extreme high and low weight classes were associated with a statistically insignificant worse VAD survival.
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mechanical ventilation (4.1% vs. 3.8% & 2.6%, p⬍0.0001) and inotropic support (46.2% vs. 42.9% & 55.2%, p⬍0.0001) were similar, they were much less likely to need mechanical circulatory support (MCS) at TXPL (7.5% vs 34.3% & 15.8%, p⬍0.0001). A higher proportion of CHD patients had body mass index less than 20 (31.1% vs. 10.9% & 16.9%, p⬍0.0001). Overall post-TXPL survival was significantly lower in the CHD group, mostly due to decreased 30-day survival (Figure). Logistic regression demonstrates the significant independent effect of CHD on 30-day mortality (odds ratio 2.7, 95%CI 2.3-4.6). Other important predictors are given in Figure. Conclusions: Adults with CHD have high 30-day mortality after heart TXPL despite being younger and requiring MCS less often. This may be due to a combination of highly complex reoperative surgery and often poor preoperative systemic health.
3 Does VAD Therapy as a “Bridge to Candidacy” Apply to the Morbidly Obese? J.W. Haft1, M.A. Romano1, J.C. Matthews2, D.B. Dyke2, F.D. Pagani1 1University of Michigan, Ann Arbor, MI; 2University of Michigan, Ann Arbor, MI Purpose: Morbid obesity is a relative contraindication for heart transplantation. While ventricular assist devices (VADs) have served as a “bridge to candidacy” in patients with renal insufficiency, pulmonary hypertension, and tobacco addiction, it is unclear if morbidly obese advanced heart failure patients will lose weight on mechanical circulatory support. Methods and Materials: We reviewed our prospectively collected database of implantable mechanical circulatory support from January, 2000 to September, 2008. Weights were recorded preoperatively and during outpatient follow up visits every three months. Patients were stratified into five weight classes: Body mass index (BMI) ⬍ 20, 20 to ⬍ 25, 25 to ⬍30, 30 to ⬍ 35, and ⱖ35. Survival was determined using the Kaplan Meier method, and multivariable analysis was performed using Cox regression. Results: Of the 222 patients receiving implantable circulatory support devices, 96 were supported for at least 6 months on an outpatient basis. Average weights for the entire cohort were 86.4, 84.8, 87.3, 89.8, and 90.2 kg at baseline, 3 months, 6 months, 9 months and 1 year, respectively. BMI was essentially unchanged for all weight classes over the study period (Figure 1). Although BMI was not an independent predictor of VAD mortality, extreme high and low weight classes were associated with a statistically insignificant worse VAD survival.
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