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331: Cardiac Index, Peak Exercise Oxygen Consumption, and Listing Priority for Cardiac Transplantation
Abstracts
S111 331 Cardiac Index, Peak Exercise Oxygen Consumption, and Listing Priority for Cardiac Transplantation A.B. Methvin, V.V. Georgiopoulou, A.P. Kalogeropoulos, A. Malik, P. Anarado, M. Chowdhury, I. Hussain, W.M. Book, S.R. Laskar, J.D. Vega, A.L. Smith, J. Butler. Emory University Hospital, Atlanta, GA. Purpose: Cardiac transplantation listing and prioritization is difficult among heart failure (HF) patients who have relatively discordant peak exercise oxygen consumption (VO2) and cardiac index (CI) values. Methods and Materials: We studied 105 HF patients (50.6⫾11.4 yrs, 72% male, 62% white, EF 14.7⫾8.7%, BMI 27.8⫾4.8) on optimal medical therapy (ACE/ARB 88%, -blocker 90%, diuretic 88%, aldosterone antagonist 60%, ICD/Bi-V 90%) who underwent cardiopulmonary exercise testing and right heart catheterization for transplant evaluation. Patients were divided in 4 groups based on peak VO2 and CI; Group 1(VO2ⱖ12; CIⱖ1.8); Group 2 (VO2ⱖ12; CI⬍1.8); Group 3 (VO2⬍12; CIⱖ1.8); and Group 4 (VO2⬍12; CI⬍1.8) and compared for event-free survival (death, LVAD, or urgent transplant). Results: Overall CI was 1.9⫾0.4 L/min/m2 and peak VO2 was 12.4⫾2.8 mL/min/kg. After a median follow-up of 3.7 years, 28 (26.0%) patients had an event. Group characteristics and event-free survival are shown Table 1.
Conclusions: PGD was associated with lower 30-day, 1-year, and 5-year allograft survival rates. Surviving patients, however, did not show increased tendency towards CAV development.
Table 1
330 Blood Product Requirements during Heart Transplantation Are Significantly Higher in Patients Bridged with Continuous Flow Devices Compared to Pulsatile Flow Devices N. Uriel,1 S.-W. Pak,2 E.M. Sutton,2 Y. Naka,2 U.P. Jorde,1 D. Mancini.1 1 Columbia University, New York, NY; 2Columbia University, New York, NY. Purpose: The need for multiple blood products during orthotopic heart transplantation (OHT) complicates post operative care. Continuous flow mechanical support devices may induce bleeding diathesis, i.e., acquired von Willebrand disease. Accordingly, we compared the transfusion requirements during OHT of patients supported with continuous flow assist devices to those supported with pulsatile flow assist devices. Methods and Materials: A retrospective chart review was performed of all continuous and pulsatile flow device patients implanted between 2004 and 2009 at a large medical center. Blood product requirements were collected at the time of OHT. Results: 78 continuous flow devices (HeartMate II) and 90 pulsatile flow devices (HeartMate XVE) were implanted. 35 patients (age 53⫾2 years, 84.2% male) with HM II and 62 patients (age 53⫾2 years, 80.6% male) with HM XVE underwent OHT during the observation period. Warfarin use was higher in HM II patients (77% vs 19%, p⬍0.001), and ASA use was higher in HM XVE patients (85.9% vs 51.4%, p⬍0.001). Blood product requirements were substantially higher in HM II patients, and this difference remained significant after adjusting for Warfarin use.[table1] Conclusions: Patients bridged to OHT with continuous flow mechanical support devices had higher transfusion requirements compared to those supported by pulsatile devices. This difference was not explained by anticoagulation alone. Assessment and treatment of acquired vW disease may improve outcomes of OHT in patients bridged with continuous flow devices.
Blood Product Use during OHT
PRBC (U) Platelets (U) FFP (U) Cryoprecipitate (U) Cell Saver (U)
HMI (62)
HM II (35)
p value
3.8⫾0.5 8.6⫾6.4 4.9⫾3.6 2.2⫾3.5 3.9⫾2.3
6.3⫾0.8 12.5⫾5.4 9.6⫾4.9 4.3⫾3.6 5.0⫾4.0
0.004 0.002 0.0001 0.003 0.04
PRBC - Packed red blood cells, FFP - Fresh frozen plasma,
Ischemic, N(%) Peak VO2, mL/min/kg CI, L/min/m2 RAP, mmHg PASP, mmHg PCWP, mmHg Survival(%) 6-mo 12-mo 18-mo 24-mo
Group 1 (N⫽30)
Group 2 (N⫽25)
Group 3 (N⫽25)
Group 4 (N⫽23)
18(60.0) 14.7⫾2.1 2.2⫾0.3 6.1⫾4.5 36.0⫾11.7 14.7⫾7.2
2(7.4) 14.3⫾1.3 1.5⫾0.2 10.1⫾6.5 46.4⫾12.0 22.3⫾7.2
15(60.0) 10.2⫾1.3 2.1⫾0.3 9.2⫾4.8 46.0⫾17.1 19.5⫾9.3
7(30.4) 0.01 9.7⫾2.0 ⬍0.01 1.6⫾0.2 ⬍0.01 11.1⫾6.4 0.01 52.5⫾14.1 0.01 23.9⫾6.9 0.01
96 88 88 83
95 81 73 73
96 90 85 79
79 73 65 53
P
0.04 0.09 0.11 0.06
Conclusions: Nearly 50% of HF patients evaluated for transplantation had relatively discordant peak VO2 and CI measurements. Patients with lower peak VO2 but preserved CI had survival comparable to the 1-year posttransplant survival (12-15%); those with low CI but preserved VO2 had lower survival rate. The results suggest that the prior group may be safely monitored whereas those with low CI may benefit from early listing. 332 The Slope of Renal Function in De Novo HTxR. Can We Improve? J. Kobashigawa,1 J. Arizon,2 G. Dong,3 H.J. Eisen,4 G. Junge,5 H. Schwende,5 A. Zuckermann,6 H.B. Lehmkuhl.7 1David Geffen School of Medicine at UCLA/Cedars Sinai Heart Institute, Los Angeles, CA; 2 Hospital Universitario, Cordoba, Spain; 3Novartis Pharmaceuticals Corporation, East Hanover; 4Temple University, Philadelphia; 5Novartis Pharma, Basel, Switzerland; 6Medical University of Vienna, Vienna, Austria; 7Deutsches Herzzentrum Berlin, Berlin, Germany. Purpose: While outcome following HTx has improved, CKD often develops in this population and is associated with substantial morbidity/mortality. CKD seems to be related to immunosuppressive regimens (ISR) used. Lowering the burden of IS can be an option to improve renal function (RF). However, the reduction of ISR often translates into a higher acute rejection (AR) rate. The impact of 6 ISR on evolution of RF is reviewed with respect to the efficacy outcome. Methods and Materials: 1009 HTxR from 3 randomized trials were exposed to: (1) SD-CsA/AZA(n⫽214); (2) SD-CsA/MMF(n⫽84); (3) SDCsA/h-EVR(n⫽211); (4) SD-CsA/l-EVR(n⫽209); (5) SD-CsA/TDMEVR(n⫽100); (6) RD-CsA/TDM-EVR(n⫽191) [SD⫽standard dose; RD⫽reduced dose; h-EVR3.0 mg/d; l-EVR1.5 mg/d; TDM-EVR3-8 ng/ mL]. Efficacy and RF were followed by incidence/severity of AR,
S111 331 Cardiac Index, Peak Exercise Oxygen Consumption, and Listing Priority for Cardiac Transplantation A.B. Methvin, V.V. Georgiopoulou, A.P. Kalogeropoulos, A. Malik, P. Anarado, M. Chowdhury, I. Hussain, W.M. Book, S.R. Laskar, J.D. Vega, A.L. Smith, J. Butler. Emory University Hospital, Atlanta, GA. Purpose: Cardiac transplantation listing and prioritization is difficult among heart failure (HF) patients who have relatively discordant peak exercise oxygen consumption (VO2) and cardiac index (CI) values. Methods and Materials: We studied 105 HF patients (50.6⫾11.4 yrs, 72% male, 62% white, EF 14.7⫾8.7%, BMI 27.8⫾4.8) on optimal medical therapy (ACE/ARB 88%, -blocker 90%, diuretic 88%, aldosterone antagonist 60%, ICD/Bi-V 90%) who underwent cardiopulmonary exercise testing and right heart catheterization for transplant evaluation. Patients were divided in 4 groups based on peak VO2 and CI; Group 1(VO2ⱖ12; CIⱖ1.8); Group 2 (VO2ⱖ12; CI⬍1.8); Group 3 (VO2⬍12; CIⱖ1.8); and Group 4 (VO2⬍12; CI⬍1.8) and compared for event-free survival (death, LVAD, or urgent transplant). Results: Overall CI was 1.9⫾0.4 L/min/m2 and peak VO2 was 12.4⫾2.8 mL/min/kg. After a median follow-up of 3.7 years, 28 (26.0%) patients had an event. Group characteristics and event-free survival are shown Table 1.
Conclusions: PGD was associated with lower 30-day, 1-year, and 5-year allograft survival rates. Surviving patients, however, did not show increased tendency towards CAV development.
Table 1
330 Blood Product Requirements during Heart Transplantation Are Significantly Higher in Patients Bridged with Continuous Flow Devices Compared to Pulsatile Flow Devices N. Uriel,1 S.-W. Pak,2 E.M. Sutton,2 Y. Naka,2 U.P. Jorde,1 D. Mancini.1 1 Columbia University, New York, NY; 2Columbia University, New York, NY. Purpose: The need for multiple blood products during orthotopic heart transplantation (OHT) complicates post operative care. Continuous flow mechanical support devices may induce bleeding diathesis, i.e., acquired von Willebrand disease. Accordingly, we compared the transfusion requirements during OHT of patients supported with continuous flow assist devices to those supported with pulsatile flow assist devices. Methods and Materials: A retrospective chart review was performed of all continuous and pulsatile flow device patients implanted between 2004 and 2009 at a large medical center. Blood product requirements were collected at the time of OHT. Results: 78 continuous flow devices (HeartMate II) and 90 pulsatile flow devices (HeartMate XVE) were implanted. 35 patients (age 53⫾2 years, 84.2% male) with HM II and 62 patients (age 53⫾2 years, 80.6% male) with HM XVE underwent OHT during the observation period. Warfarin use was higher in HM II patients (77% vs 19%, p⬍0.001), and ASA use was higher in HM XVE patients (85.9% vs 51.4%, p⬍0.001). Blood product requirements were substantially higher in HM II patients, and this difference remained significant after adjusting for Warfarin use.[table1] Conclusions: Patients bridged to OHT with continuous flow mechanical support devices had higher transfusion requirements compared to those supported by pulsatile devices. This difference was not explained by anticoagulation alone. Assessment and treatment of acquired vW disease may improve outcomes of OHT in patients bridged with continuous flow devices.
Blood Product Use during OHT
PRBC (U) Platelets (U) FFP (U) Cryoprecipitate (U) Cell Saver (U)
HMI (62)
HM II (35)
p value
3.8⫾0.5 8.6⫾6.4 4.9⫾3.6 2.2⫾3.5 3.9⫾2.3
6.3⫾0.8 12.5⫾5.4 9.6⫾4.9 4.3⫾3.6 5.0⫾4.0
0.004 0.002 0.0001 0.003 0.04
PRBC - Packed red blood cells, FFP - Fresh frozen plasma,
Ischemic, N(%) Peak VO2, mL/min/kg CI, L/min/m2 RAP, mmHg PASP, mmHg PCWP, mmHg Survival(%) 6-mo 12-mo 18-mo 24-mo
Group 1 (N⫽30)
Group 2 (N⫽25)
Group 3 (N⫽25)
Group 4 (N⫽23)
18(60.0) 14.7⫾2.1 2.2⫾0.3 6.1⫾4.5 36.0⫾11.7 14.7⫾7.2
2(7.4) 14.3⫾1.3 1.5⫾0.2 10.1⫾6.5 46.4⫾12.0 22.3⫾7.2
15(60.0) 10.2⫾1.3 2.1⫾0.3 9.2⫾4.8 46.0⫾17.1 19.5⫾9.3
7(30.4) 0.01 9.7⫾2.0 ⬍0.01 1.6⫾0.2 ⬍0.01 11.1⫾6.4 0.01 52.5⫾14.1 0.01 23.9⫾6.9 0.01
96 88 88 83
95 81 73 73
96 90 85 79
79 73 65 53
P
0.04 0.09 0.11 0.06
Conclusions: Nearly 50% of HF patients evaluated for transplantation had relatively discordant peak VO2 and CI measurements. Patients with lower peak VO2 but preserved CI had survival comparable to the 1-year posttransplant survival (12-15%); those with low CI but preserved VO2 had lower survival rate. The results suggest that the prior group may be safely monitored whereas those with low CI may benefit from early listing. 332 The Slope of Renal Function in De Novo HTxR. Can We Improve? J. Kobashigawa,1 J. Arizon,2 G. Dong,3 H.J. Eisen,4 G. Junge,5 H. Schwende,5 A. Zuckermann,6 H.B. Lehmkuhl.7 1David Geffen School of Medicine at UCLA/Cedars Sinai Heart Institute, Los Angeles, CA; 2 Hospital Universitario, Cordoba, Spain; 3Novartis Pharmaceuticals Corporation, East Hanover; 4Temple University, Philadelphia; 5Novartis Pharma, Basel, Switzerland; 6Medical University of Vienna, Vienna, Austria; 7Deutsches Herzzentrum Berlin, Berlin, Germany. Purpose: While outcome following HTx has improved, CKD often develops in this population and is associated with substantial morbidity/mortality. CKD seems to be related to immunosuppressive regimens (ISR) used. Lowering the burden of IS can be an option to improve renal function (RF). However, the reduction of ISR often translates into a higher acute rejection (AR) rate. The impact of 6 ISR on evolution of RF is reviewed with respect to the efficacy outcome. Methods and Materials: 1009 HTxR from 3 randomized trials were exposed to: (1) SD-CsA/AZA(n⫽214); (2) SD-CsA/MMF(n⫽84); (3) SDCsA/h-EVR(n⫽211); (4) SD-CsA/l-EVR(n⫽209); (5) SD-CsA/TDMEVR(n⫽100); (6) RD-CsA/TDM-EVR(n⫽191) [SD⫽standard dose; RD⫽reduced dose; h-EVR3.0 mg/d; l-EVR1.5 mg/d; TDM-EVR3-8 ng/ mL]. Efficacy and RF were followed by incidence/severity of AR,