- Email: [email protected]
204: Does Access to Device Therapies Affect Transplant Outcomes for Adults with Congenital Heart Disease? Analysis of the United Network for Organ Sharing (UNOS) Database
Abstracts age- and immunosuppresion-matched controls. Student t-test was used to analyze differences between the patients and controls. Results: There were 6 patients and 6 controls. Mean age of patients was 12.8 years (Range:7-18 years). The average time between HSCT and lung transplantation was 4.2 years. Number of any grade acute rejection episode per patient per biopsy was significantly lower in patients than in controls: 0.0 vs. 0.11, respectively, p⬍0.05. HSCT lung transplant recipients were hospitalized at a rate of 1.66 admissions/ patient in the first year in comparison to 1.33 admissions/ patient for controls, p⫽0.43. While 90% of hospitalizations in HSCT lung transplant recipients were due to infectious reasons, only 33% of admissions in controls were related to infections (p⬍0.05). 1 year survival was 67% and 100% in patients and controls, respectively, p⬍0.05. All deaths were related to infection in HSCT lung transplant recipients. Conclusions: Outcomes of lung transplantation after HSCT in children are hampered by infectious complications. Increased vigilance, aggressive pre-emptive therapy and early intervention may improve outcomes. 202 Outcomes of Heart Transplantation for Patients with Systemic Muscular Disorders N. Cain,1 J. Teuteberg,2 B. Feingold,1 S. Miller,1 E. Quivers,1 V. Morell,1 P. Wearden,1 R. Kormos,2 Y. Toyoda,2 D. McNamara,2 C. Chrysostomou,1 V. Gerard,1 S. Webber.1 1Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA; 2UPMC Presbyterian, Pittsburgh, PA. Purpose: Heart transplantation (Tx) is a successful therapy for end-stage cardiomyopathy. Its utility in patients with systemic myopathy due to primary muscle disease or systemic metabolic disorders is ill defined. Our objective was to evaluate the post-operative outcomes in patients with systemic muscle weakness who underwent Tx for cardiomyopathy. Methods and Materials: From our Tx database, we identified 16 recipients who had undergone Tx for the above indications since 1980. The median age at Tx was 15.6 years (IQR 12.6 –22.4 yr). This included 12/254 (4.7%) pediatric and 4/1216 (0.3%) adult Txs. Diagnoses were: muscular dystrophy in 8 (50%) (Becker 4, Limb-Girdle 2, Duchenne 1, not-specified 1); primary myopathy 4 (25%) (Congenital Fiber-type Disproportion, Nemaline, Myosin, Myofibrillar myopathy); metabolic disorders 3 (19%) (Barth Syndrome, CPT-II deficiency, Complex IV deficiency); and 1 child with Danon disease. Results: The median follow-up after Tx was 3.3 years (0.58-6.4 yr). The median time to extubation was 2 days (1-2 d). The median ICU stay was 6 days (4-10 d). The median length of hospitalization was 19 days (16-22 d). Four died during follow-up; 1 from perioperative pulmonary embolus, 2 from sepsis at 3 and 34 months, and 1 from late graft failure at 6.4 years. The probability of patient survival at 1 and 5 years was 87% and 78%. No patient has died of pneumonia or respiratory failure and one patient required post-Tx tracheostomy for less than 6 months. One patient is wheelchair bound but was transplanted from this state. The child with Barth syndrome has required chronic use of filgrastim. Tx of the child with CPT-II deficiency resulted in cessation of admissions for hypoglycemia and metabolic crises. Conclusions: Tx is a suitable therapy for highly selected candidates with systemic muscle weakness secondary to primary muscle or metabolic disease. Most such candidates are children. The post-tx course, including medium-term survival, is comparable to our entire Tx cohort. Patients referred for these diagnoses warrant careful consideration and evaluation. 203 Comparison of Risk Factors and Outcomes for Pediatric Patients Listed for Heart Transplantation after Bidirectional Glenn and after Fontan: A Multi-Institutional Study J.R. Kovach,1 E.D. Blume,6 D.C. Naftel,2 F.B. Pearce,3 M.T. Foushee,2 E.R. Edens,4 J.H. Shuhaiber,5 F. Fynn-Thompson,6 J.K. Kirklin,2 S.D. Zangwill.1 1Medical College of Wisconsin, Milwaukee, WI; 2 University of Alabama at Birmingham, Birmingham, AL; 3University of Alabama at Birmingham, Birmingham, AL; 4University of Iowa Children’s Hospital, Iowa City, IA; 5Cincinnati Children’s Hospital, Cincinnati, OH; 6Children’s Hospital Boston, Boston, MA.
S71 Purpose: While outcomes for patients with single-ventricle physiology undergoing staged palliation continue to improve; a subset of patients still require cardiac transplantation (tx) for progressive heart failure. This study compares risk factors and outcomes for patients listed for tx after bidirectional Glenn (BDG) to those listed after Fontan. Methods and Materials: A retrospective, multi-institutional review was performed of 262 BDG and 269 Fontan patients listed at 32 Pediatric Heart Transplant Study centers from 1993 to 2008. Results: BDG patients were significantly younger than their Fontan counterparts both at listing (med 2.4 yrs v. 9.7 yrs, p⬍0.0001) and at tx (med 2.9 yrs v. 11.6 yrs, p⬍0.0001). At listing, BDG patients were more likely to have failure-to-thrive (p⫽0.002) while Fontans were more likely to have arrhythmias (p⫽0.001). Competing outcomes analyses for BDG and Fontans post-listing revealed similar rates of tx and death while waiting. Univariate analyses showed that age, mechanical ventilation, and UNOS status 1 were associated with increased mortality while waiting for both groups. 189 BDG and 194 Fontan patients underwent heart tx. BDG patients were more likely to require mechanical ventilation at tx (p⫽.02). Post-tx survival was similar for both groups (p⫽.8). While age and UNOS status were risk factors for death while waiting for both groups, they did not impact mortality post-tx. While mechanical ventilation was a risk factor for death while waiting in both groups, it was a risk factor for death post-tx only for Fontans (p⫽.04). Despite a trend, there was no significant era effect on outcomes in either group post-listing or post-tx. Conclusions: Overall survival for patients listed for tx after either BDG or Fontan are similar. Mechanical ventilation at the time of tx was a statistically significant risk factor for death in Fontan patients but not in BDGs. Fontan patients in particular may have better outcomes if listed prior to becoming ventilator-dependent. 204 Does Access to Device Therapies Affect Transplant Outcomes for Adults with Congenital Heart Disease? Analysis of the United Network for Organ Sharing (UNOS) Database M.D. Everitt,1,2 A.T. Yetman,1,2 A.E. Donaldson,2 J. Stehlik,2 A.K. Kaza,1,2 D. Budge,3 R. Alharethi,3 E.A. Bullock,1 M. Cardon,1 L.T. Tani,1,2 A.G. Kfoury.3 1Primary Children’s Medical Center, Salt Lake City, UT; 2University of Utah, Salt Lake City, UT; 3Intermountain Medical Center, Salt Lake City, UT. Purpose: Patients with congenital heart disease (CHD) now survive into adulthood and often present with end stage heart failure (HF). Given the complexity of CHD, issues related to HF treatment and transplant may differ from adults who do not have CHD (no CHD). We sought to compare transplant waitlist characteristics and outcomes for these 2 patient groups. Methods and Materials: The Organ Procurement and Transplantation Network (OPTN)/UNOS database was used to identify adults ⱖ18 yrs old listed for heart transplant from 2005-2009. The cohort was divided by diagnosis: CHD and no CHD.
Patient characteristics at listing
Age, yrs Prior cardiac surgery,% Status at listing,% 1A 1B 2 Inotropes, % Ventilation,% Cardiac output, L/min ICDⴱ,% Mechanical circulatory supportⴱ, % ECMO IABP VAD
CHD
no CHD
p
35 85
52 34
⬍0.001 ⬍0.001 ⬍0.001
10 25 63 24 3 4.4⫾1.5 45 9 1.6 2 5
19 35 43 34 3 4.3⫾1.4 75 20 0.4 6 15
⬍0.001 0.8 0.2 ⬍0.001 ⬍0.001 0.01 0.01 ⬍0.001
ⴱ ICD⫽defibrillator, ECMO⫽extracorporeal membrane oxygenation, IABP⫽aortic balloon pump, VAD⫽ventricular assist device.
S72
The Journal of Heart and Lung Transplantation, Vol 29, No 2S, February 2010
Results: Based on OPTN data as of May 26, 2009, 10054 adults were listed for transplant, of whom 318 (3%) had CHD and 9736 (97%) did not. Characteristics at listing are shown in table 1. [table1]Fewer CHD patients achieved transplant (53% v 65%, p⬍0.001). Waitlist mortality did not differ between groups (10% v 8%, p⫽0.2). Cause of death was arrest or arrhythmia (39%), ventricular failure (15%), and end organ failure (15%) in the CHD group. Conclusions: Despite lower acuity status at listing, patients with CHD have comparable waitlist mortality. Arrest, arrhythmias, and ventricular failure are major causes of death. Lower prevalence of ICD and VAD use raises the possibility of disparate access to device therapies in this population and warrants further exploration to limit adverse outcomes. 205 Cardiac Resynchronization Therapy (CRT) Induced Cellular Reverse Cardiac Remodeling Similar to Left Ventricular Assist Devices C.M. Orrego, J. Florez, K. Youker, G. Torre-Amione. The Methodist Hospital, Houston, TX. Purpose: Mechanical circulatory support provided by Left Ventricular Assist Devices (LVADs) induce reverse cardiac remodeling characterized by a reduction of myocyte size and collagen deposition as well as deactivation of cardiac inflammatory markers. On the other hand, CRT reverses left ventricular remodeling by improving electro-mechanical disynchrony which translates into improvements in quality of life, exercise capacity, and more importantly in reduction of morbidity and mortality. However, little is known about the effect of CRT at celular level. Methods and Materials: We included patients with Chronic Heart Failure who were eligible for either CRT or LVAD according to standard of care for both groups. We analyzed demographics, echocardiographic parameters and histological samples from myocardial biopsies for 12 in the CRT group and 17 patients in the LVAD group, and compared with 8 normal controls. Results: We found a statistical significant decreased in myocyte size and TNF-␣ expression (p ⬍ 0.05) pre and post CRT implantation. We also found that myocyte size, total collagen content and TNF-␣ decreased by 13%, 27% and 49% respectively in the CRT group that was comprable to 28%, 38% and 39% in the LVAD group (Figure 1). These finding demonstrate that the use of CRT in patients that were clinically eligible for implantation of the device was associated with reverse cardiac remodeling as demonstrated by a reduction in myocyte size, total collagen content and decrease myocardial TNF-␣ expression.[figure1]
Conclusions: CRT produces positive cellular changes, cellular reverse remodeling in failing human hearts that are comparable to those produced by LVAD.
Purpose: Some patients with advanced HF develop severe PH. Testing of PH reversibility is therefore used for selection of Tx candidates. The aim of our study was to compare the effects of PGE1, an agent mostly used at our institution, with novel potent pulmonary vasodilator–sildenafil citrate on hemodynamics in patients with chronic HF and severe PH. Methods and Materials: We performed 263 RHC as a part of pre-Tx work-up. In 16 patients (6%), pulmonary hemodynamics mandated testing of reversibility (TPG⬎15 mmHg or PVR⬎3 w.u. in euvololemia). RHC was performed using thermodilution SG catheter, systemic blood pressure was monitored invasively from radial artery. Hemodynamic parameters was measured at the baseline, after 5 min of continuous infusion of PGE1 (Alprostan, Leciva, 200 ug/kg/min), and 1h after single oral dose of Sildenafil 40 mg (Revatio, Pfizer). Drug-induced changes from baseline were compared with paired t statistics. Results: Results are summarized in the Table. Both drugs TPG, PVR and TVR and increased CO. The effect of sildenafil on PVR and pulmonary selectivity ratio (TSR/PVR) was significantly higher than the effects of PGE1.
Heart rate, /min PA mean, mmHg PA wedged pressure, mmHg Cardiac output, l/min Pulmonary vascular resistance, w.u. Total systemic resistance, w.u. TSR/PVR
rest
⌬ PGE 1
⌬ sildenafil
p ⌬S x ⌬PG
82.6⫾13 49.6⫾5.4 25.5⫾3.7 3.5⫾0.8 7.1⫾2.2
⫺0.3⫾6.8 ⫺6.3⫾7.5ⴱ ⫺4.9⫾6.1ⴱ ⫺0.4⫾1.2† ⫺1.6⫾2.3ⴱ
⫺7.0⫾8.0ⴱ ⫺12.3⫾7.1† ⫺2.6⫾5.8 0.8⫾0.7† ⫺3.5⫾1.6†
0.088 0.019 0.471 0.318 0.027
26.1⫾7.6 3.8⫾1.0
⫺7.0⫾3.9† 0.1⫾1.8
-7.3⫾5.7† 2.6⫾2.2†
0.655 0.009
Conclusions: Sildenafil had superior ability to unmask reversible PH secondary to advanced HF than PGE1. Hemodynamic testing using sindenafil is viable alternative to PGE1. 207 Electrocardiogram QRS Duration Predicts Recovery of Left Ventricular Ejection Fraction after Renal Transplant P.S.D. Yeo,1 R. Fatica,2 W.W.H. Tang.1 1Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic, Cleveland, OH. Purpose: Renal transplant in patients with end-stage renal failure and concomitant left ventricular (LV) systolic dysfunction carries increased perioperative risk. Concomitant cardiac transplantation must be considered. It is known that LV ejection fraction (LVEF) recovers and even normalizes in some patients after renal transplant without heart transplant. Methods and Materials: We did a retrospective records review of all patients who had a renal transplant at the Cleveland Clinic from 1/1/2003 to 12/31/2007. Of 753 patients, we excluded those with combined (3) or recent (1) heart transplant. 47 had impaired LVEF before renal transplant. Results: Patients were 52 ⫾ 13 years old, 32% female, 68% white, 23% black, with baseline LVEF 39.6 ⫾ 9.8%. LVEF normalized in 24 and did not improve in 8. Those who did not improve had higher body-mass index (BMI) (30.4 ⫾ 3.1) and wider QRS duration (126 msec) on the electrocardiogram, compared with those which normalized (BMI 26.7 ⫾ 5.1, p⫽0.0258; QRS 95msec, p⫽0.0087).
S/No
n
Post-renal Transplant LVEF
Age (years)
BMI (Wt/ Ht2) (kg/m2)
Baseline LVEF %
PostTransplant LVEF %
Baseline QRS (msec)
1 2 3 4
47 8 15 24
Overall Severely impaired Mild to Moderately impaired Normalized 2-tailed T-test of 2 vs 3 2-tailed T-test of 2 vs 4 2-tailed T-test of 3 vs 4
52 ⫾ 13 57 ⫾ 10 55 ⫾ 10 49 ⫾ 15 0.609 0.0858 0.133
26.5 ⫾ 4.8 30.4 ⫾ 3.1 24 ⫾ 3.5 26.7 ⫾ 5.1 0.00039 0.0258 0.0572
39.6 ⫾ 9.8 30.4 ⫾ 10.2 40.3 ⫾ 6.6 42.2 ⫾ 9.8 0.0321 0.0147 0.475
49.6 ⫾ 14.7 24.8 ⫾ 6.4 44.6 ⫾ 6.0 61.1 ⫾ 6.4 ⬍0.0005 ⬍0.0005 ⬍0.0005
105 ⫾ 23 126 ⫾ 24 108 ⫾ 26 95 ⫾ 16 0.118 0.00870 0.102
206 Sildenafil Is More Selective Pulmonary Vasodilator than PGE1 in Patients with Severe Pulmonary Hypertension Secondary to Heart Failure H. Al-Hiti, V. Melenovsky, J. Kettner, J. Kautzner. IKEM, Prague, Czech Republic.
Conclusions: Patients whose LVEF normalized after renal transplant had a narrower QRS and lower BMI than those who did not. These are new predictors of outcome which will help clinical decision-making in this patient group.
S71 Purpose: While outcomes for patients with single-ventricle physiology undergoing staged palliation continue to improve; a subset of patients still require cardiac transplantation (tx) for progressive heart failure. This study compares risk factors and outcomes for patients listed for tx after bidirectional Glenn (BDG) to those listed after Fontan. Methods and Materials: A retrospective, multi-institutional review was performed of 262 BDG and 269 Fontan patients listed at 32 Pediatric Heart Transplant Study centers from 1993 to 2008. Results: BDG patients were significantly younger than their Fontan counterparts both at listing (med 2.4 yrs v. 9.7 yrs, p⬍0.0001) and at tx (med 2.9 yrs v. 11.6 yrs, p⬍0.0001). At listing, BDG patients were more likely to have failure-to-thrive (p⫽0.002) while Fontans were more likely to have arrhythmias (p⫽0.001). Competing outcomes analyses for BDG and Fontans post-listing revealed similar rates of tx and death while waiting. Univariate analyses showed that age, mechanical ventilation, and UNOS status 1 were associated with increased mortality while waiting for both groups. 189 BDG and 194 Fontan patients underwent heart tx. BDG patients were more likely to require mechanical ventilation at tx (p⫽.02). Post-tx survival was similar for both groups (p⫽.8). While age and UNOS status were risk factors for death while waiting for both groups, they did not impact mortality post-tx. While mechanical ventilation was a risk factor for death while waiting in both groups, it was a risk factor for death post-tx only for Fontans (p⫽.04). Despite a trend, there was no significant era effect on outcomes in either group post-listing or post-tx. Conclusions: Overall survival for patients listed for tx after either BDG or Fontan are similar. Mechanical ventilation at the time of tx was a statistically significant risk factor for death in Fontan patients but not in BDGs. Fontan patients in particular may have better outcomes if listed prior to becoming ventilator-dependent. 204 Does Access to Device Therapies Affect Transplant Outcomes for Adults with Congenital Heart Disease? Analysis of the United Network for Organ Sharing (UNOS) Database M.D. Everitt,1,2 A.T. Yetman,1,2 A.E. Donaldson,2 J. Stehlik,2 A.K. Kaza,1,2 D. Budge,3 R. Alharethi,3 E.A. Bullock,1 M. Cardon,1 L.T. Tani,1,2 A.G. Kfoury.3 1Primary Children’s Medical Center, Salt Lake City, UT; 2University of Utah, Salt Lake City, UT; 3Intermountain Medical Center, Salt Lake City, UT. Purpose: Patients with congenital heart disease (CHD) now survive into adulthood and often present with end stage heart failure (HF). Given the complexity of CHD, issues related to HF treatment and transplant may differ from adults who do not have CHD (no CHD). We sought to compare transplant waitlist characteristics and outcomes for these 2 patient groups. Methods and Materials: The Organ Procurement and Transplantation Network (OPTN)/UNOS database was used to identify adults ⱖ18 yrs old listed for heart transplant from 2005-2009. The cohort was divided by diagnosis: CHD and no CHD.
Patient characteristics at listing
Age, yrs Prior cardiac surgery,% Status at listing,% 1A 1B 2 Inotropes, % Ventilation,% Cardiac output, L/min ICDⴱ,% Mechanical circulatory supportⴱ, % ECMO IABP VAD
CHD
no CHD
p
35 85
52 34
⬍0.001 ⬍0.001 ⬍0.001
10 25 63 24 3 4.4⫾1.5 45 9 1.6 2 5
19 35 43 34 3 4.3⫾1.4 75 20 0.4 6 15
⬍0.001 0.8 0.2 ⬍0.001 ⬍0.001 0.01 0.01 ⬍0.001
ⴱ ICD⫽defibrillator, ECMO⫽extracorporeal membrane oxygenation, IABP⫽aortic balloon pump, VAD⫽ventricular assist device.
S72
The Journal of Heart and Lung Transplantation, Vol 29, No 2S, February 2010
Results: Based on OPTN data as of May 26, 2009, 10054 adults were listed for transplant, of whom 318 (3%) had CHD and 9736 (97%) did not. Characteristics at listing are shown in table 1. [table1]Fewer CHD patients achieved transplant (53% v 65%, p⬍0.001). Waitlist mortality did not differ between groups (10% v 8%, p⫽0.2). Cause of death was arrest or arrhythmia (39%), ventricular failure (15%), and end organ failure (15%) in the CHD group. Conclusions: Despite lower acuity status at listing, patients with CHD have comparable waitlist mortality. Arrest, arrhythmias, and ventricular failure are major causes of death. Lower prevalence of ICD and VAD use raises the possibility of disparate access to device therapies in this population and warrants further exploration to limit adverse outcomes. 205 Cardiac Resynchronization Therapy (CRT) Induced Cellular Reverse Cardiac Remodeling Similar to Left Ventricular Assist Devices C.M. Orrego, J. Florez, K. Youker, G. Torre-Amione. The Methodist Hospital, Houston, TX. Purpose: Mechanical circulatory support provided by Left Ventricular Assist Devices (LVADs) induce reverse cardiac remodeling characterized by a reduction of myocyte size and collagen deposition as well as deactivation of cardiac inflammatory markers. On the other hand, CRT reverses left ventricular remodeling by improving electro-mechanical disynchrony which translates into improvements in quality of life, exercise capacity, and more importantly in reduction of morbidity and mortality. However, little is known about the effect of CRT at celular level. Methods and Materials: We included patients with Chronic Heart Failure who were eligible for either CRT or LVAD according to standard of care for both groups. We analyzed demographics, echocardiographic parameters and histological samples from myocardial biopsies for 12 in the CRT group and 17 patients in the LVAD group, and compared with 8 normal controls. Results: We found a statistical significant decreased in myocyte size and TNF-␣ expression (p ⬍ 0.05) pre and post CRT implantation. We also found that myocyte size, total collagen content and TNF-␣ decreased by 13%, 27% and 49% respectively in the CRT group that was comprable to 28%, 38% and 39% in the LVAD group (Figure 1). These finding demonstrate that the use of CRT in patients that were clinically eligible for implantation of the device was associated with reverse cardiac remodeling as demonstrated by a reduction in myocyte size, total collagen content and decrease myocardial TNF-␣ expression.[figure1]
Conclusions: CRT produces positive cellular changes, cellular reverse remodeling in failing human hearts that are comparable to those produced by LVAD.
Purpose: Some patients with advanced HF develop severe PH. Testing of PH reversibility is therefore used for selection of Tx candidates. The aim of our study was to compare the effects of PGE1, an agent mostly used at our institution, with novel potent pulmonary vasodilator–sildenafil citrate on hemodynamics in patients with chronic HF and severe PH. Methods and Materials: We performed 263 RHC as a part of pre-Tx work-up. In 16 patients (6%), pulmonary hemodynamics mandated testing of reversibility (TPG⬎15 mmHg or PVR⬎3 w.u. in euvololemia). RHC was performed using thermodilution SG catheter, systemic blood pressure was monitored invasively from radial artery. Hemodynamic parameters was measured at the baseline, after 5 min of continuous infusion of PGE1 (Alprostan, Leciva, 200 ug/kg/min), and 1h after single oral dose of Sildenafil 40 mg (Revatio, Pfizer). Drug-induced changes from baseline were compared with paired t statistics. Results: Results are summarized in the Table. Both drugs TPG, PVR and TVR and increased CO. The effect of sildenafil on PVR and pulmonary selectivity ratio (TSR/PVR) was significantly higher than the effects of PGE1.
Heart rate, /min PA mean, mmHg PA wedged pressure, mmHg Cardiac output, l/min Pulmonary vascular resistance, w.u. Total systemic resistance, w.u. TSR/PVR
rest
⌬ PGE 1
⌬ sildenafil
p ⌬S x ⌬PG
82.6⫾13 49.6⫾5.4 25.5⫾3.7 3.5⫾0.8 7.1⫾2.2
⫺0.3⫾6.8 ⫺6.3⫾7.5ⴱ ⫺4.9⫾6.1ⴱ ⫺0.4⫾1.2† ⫺1.6⫾2.3ⴱ
⫺7.0⫾8.0ⴱ ⫺12.3⫾7.1† ⫺2.6⫾5.8 0.8⫾0.7† ⫺3.5⫾1.6†
0.088 0.019 0.471 0.318 0.027
26.1⫾7.6 3.8⫾1.0
⫺7.0⫾3.9† 0.1⫾1.8
-7.3⫾5.7† 2.6⫾2.2†
0.655 0.009
Conclusions: Sildenafil had superior ability to unmask reversible PH secondary to advanced HF than PGE1. Hemodynamic testing using sindenafil is viable alternative to PGE1. 207 Electrocardiogram QRS Duration Predicts Recovery of Left Ventricular Ejection Fraction after Renal Transplant P.S.D. Yeo,1 R. Fatica,2 W.W.H. Tang.1 1Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic, Cleveland, OH. Purpose: Renal transplant in patients with end-stage renal failure and concomitant left ventricular (LV) systolic dysfunction carries increased perioperative risk. Concomitant cardiac transplantation must be considered. It is known that LV ejection fraction (LVEF) recovers and even normalizes in some patients after renal transplant without heart transplant. Methods and Materials: We did a retrospective records review of all patients who had a renal transplant at the Cleveland Clinic from 1/1/2003 to 12/31/2007. Of 753 patients, we excluded those with combined (3) or recent (1) heart transplant. 47 had impaired LVEF before renal transplant. Results: Patients were 52 ⫾ 13 years old, 32% female, 68% white, 23% black, with baseline LVEF 39.6 ⫾ 9.8%. LVEF normalized in 24 and did not improve in 8. Those who did not improve had higher body-mass index (BMI) (30.4 ⫾ 3.1) and wider QRS duration (126 msec) on the electrocardiogram, compared with those which normalized (BMI 26.7 ⫾ 5.1, p⫽0.0258; QRS 95msec, p⫽0.0087).
S/No
n
Post-renal Transplant LVEF
Age (years)
BMI (Wt/ Ht2) (kg/m2)
Baseline LVEF %
PostTransplant LVEF %
Baseline QRS (msec)
1 2 3 4
47 8 15 24
Overall Severely impaired Mild to Moderately impaired Normalized 2-tailed T-test of 2 vs 3 2-tailed T-test of 2 vs 4 2-tailed T-test of 3 vs 4
52 ⫾ 13 57 ⫾ 10 55 ⫾ 10 49 ⫾ 15 0.609 0.0858 0.133
26.5 ⫾ 4.8 30.4 ⫾ 3.1 24 ⫾ 3.5 26.7 ⫾ 5.1 0.00039 0.0258 0.0572
39.6 ⫾ 9.8 30.4 ⫾ 10.2 40.3 ⫾ 6.6 42.2 ⫾ 9.8 0.0321 0.0147 0.475
49.6 ⫾ 14.7 24.8 ⫾ 6.4 44.6 ⫾ 6.0 61.1 ⫾ 6.4 ⬍0.0005 ⬍0.0005 ⬍0.0005
105 ⫾ 23 126 ⫾ 24 108 ⫾ 26 95 ⫾ 16 0.118 0.00870 0.102
206 Sildenafil Is More Selective Pulmonary Vasodilator than PGE1 in Patients with Severe Pulmonary Hypertension Secondary to Heart Failure H. Al-Hiti, V. Melenovsky, J. Kettner, J. Kautzner. IKEM, Prague, Czech Republic.
Conclusions: Patients whose LVEF normalized after renal transplant had a narrower QRS and lower BMI than those who did not. These are new predictors of outcome which will help clinical decision-making in this patient group.