- Email: [email protected]
465 Mechanical Unloading through Ventricular Assist Device Implantation Corrects Adiponectin Resistance in Patients with Advanced Heart Failure
S158
The Journal of Heart and Lung Transplantation, Vol 30, No 4S, April 2011
Conclusions: Combined HFMED and CF LVAD support led to cardiac improvement in half the patients. This approach to management after CF LVAD is safe and should encourage further study. 463 Increased Levels of Retinol Binding Protein 4 in Patients with Severe Heart Failure Correct after Hemodynamic Improvement through Ventricular Assist Device Placement N. Chavarria,1 F.H. Cheema,2 R. Khan,1 A. Chokshi,1 E. Collado,1 T. Kato,1 H. Takayama,2 Y. Naka,2 M. Farr,1 D.M. Mancini,1 P.C. Schulze.1 1Cardiology/Medicine, Columbia University Medical Center, New York, NY; 2Cardiothoracic Surgery, Columbia University Medical Center, New York, NY. Purpose: The syndrome of chronic heart failure (CHF) is associated with impaired glucose homeostasis and insulin resistance. Secretory products from adipocytes such as retinol binding protein 4 (RBP4), an adipose tissue-derived protein with prodiabetogenic effects, have been linked to the deterioration in glycemic control. The purpose of this study was to examine the relationship of RBP4 and insulin resistance in patients with advanced heart failure. Methods and Materials: Serum levels of RBP4, insulin and fasting glucose were assessed in patients with severe heart failure before and after left ventricular assist device (LVAD) implantation (n⫽62, mean age 57.9⫾12.6 years, mean ejection fraction 17.9 ⫾6.1%). Plasma levels of RBP4 were measured by ELISA and insulin resistance was assessed by the Homeostatic Model of Insulin Resistance (HOMA-IR). Results: At the time of LVAD implantation, RBP4 levels were significantly increased in severe heart failure patients compared to controls (21.8⫾8.8 vs. 16.0⫾3.9 mg/dL in controls; p⬍0.01) with normalization following LVAD removal (16.5⫾3.9mg/dL; p⬍0.05 vs. HF). RBP-4 levels correlated with concomitant increases in fasting glucose levels (R⫽0.3; p⬍0.05) and showed a trend towards correlation with HOMA-IR (R⫽0.242; p⫽0.08). Glucose homeostasis improved after LVAD with reduced HOMA-IR (4.05⫾2.6 vs. 2.6⫾1.9, p⫽0.007). Conclusions: Advanced heart failure is characterized by elevated levels of RBP4 which normalize after hemodynamic improvement through LVAD implantation. Circulating levels of RBP4 link adipocyte activation to impaired glucose homeostasis in advanced heart failure and suggest a novel role of adipose tissue in the pathogenesis of the syndrome of CHF. These findings underscore the role of systemic and local metabolic derangements in advanced heart failure and the potential reversibility of these abnormalities after correction of central hemodynamics through LVAD implantation. 464 Systolic Augmentation of Continuous Aortic Regurgitation: A Novel Marker of Increased Fractional Shortening and Flow in HeartMate II Supported Patients A. Agarwal, M. Padmalingam, R. Mohan, R. Banifatemi, J. Fontaine, S. Hankins, H. Eisen, J. Plehn. Division of Cardiology, Drexel University College of Medicine, Philadelphia, PA. Purpose: Prior observations suggest that continuous aortic regurgitation
(AR) is common following HeartMate II (HMII) placement but systolic augmentation of aortic regurgitation (SARA) has not been reported. We hypothesize that this finding is due to improved left ventricular systolic function and enhanced systolic aortic flow. Methods and Materials: We measured LV shortening(FS), mean arterial pressure(MAP), pump flow(PF), and SARA index(maximum aortic regurgitant systolic jet diameter-maximum aortic regurgitant diastolic jet diameter/maximum systolic aortic regurgitant jet diameter x 100%) in 29 adult HM II patients at baseline(0-30days post implant) and up to two years follow-up (mean 348.36⫾286.73 days). Significant AR was 2⫹ or greater. We also recorded aortic root dimension, aortic root index, pump speed and power, pulsatility index, and number of blood pressure (BP) medications at baseline and follow up (f/u). In the SARA⫹ and SARA-groups, the above parameters were compared at baseline and f/u. Results: Patients undergoing aortic valve repair at time of HMII placement or those with inadequate studies were excluded (n⫽7). SARA with continuous AR was noted in 3/22 pts at baseline and 11/22 (50%) at f/u. In the SARA⫹ group, the mean time to develop significant AR was 318⫾322.3 days. SARA index increased over seven fold from baseline to f/u (12.64⫾27.53vs.99.07⫾80.26,p⫽0.003), while FS did not increase significantly (10.9vs.15.5 cm,p⫽0.22). Change in FS correlated with change in SARA index(r⫽ 0.859). In the SARA⫹ group, PF increased (4.80⫾0.86vs.6.06 ⫾1.25 L/min,p⫽ 0.012). MAP was unchanged (92.82⫾11.77vs.92.91⫾22.91,p⫽NS). At f/u, the SARA⫹ group took more BP medications (0.9⫾0.7vs.1.6⫾0.69,p⫽0.02). In the SARA- group, PF (5.2vs.5.6), FS (6.1vs.9.4), MAP (91.4vs.89.6), and number of BP medications (0.6vs.0.8) did not increase significantly. Conclusions: SARA is a novel finding that reflects LV systolic recovery. This observation warrants closer evaluation of LV systolic and valvular function. 465 Mechanical Unloading through Ventricular Assist Device Implantation Corrects Adiponectin Resistance in Patients with Advanced Heart Failure R.S. Khan,1 A. Chokshi,1 M. Chew,1 S. Yu,1 P. Singh,1 F. Cheema,2 H. Takayama,2 Y. Naka,2 M.-J. Farr,1 D. Mancini,1 P.C. Schulze.1 1 Cardiology/Medicine, Columbia University Medical Center, New York, NY; 2Cardiothoracic Surgery, Columbia University Medical Center, New York, NY. Purpose: Heart failure is characterized by inflammation, insulin resistance (IR) and elevations in adipokines. Abnormal adiponectin receptor signaling has been linked to metabolic abnormalities in heart failure. We hypothesized that hemodynamic correction through implantation of a ventricular assist device (VAD) would reverse adipocyte activation and correct adiponectin signaling in patients with HF. Methods and Materials: Serum was collected from 18 subjects with HF before and after VAD implantation and 10 control subjects. Gene and protein expression of adiponectin in adipose tissue and their receptors in skeletal muscle and myocardium were assessed. Serum levels of insulin and adiponectin were measured by ELISA, and IR calculated using HOMA-IR. Results: The study population had a mean age of 55⫾13.4 years, ejection fraction of 18⫾5.5% and VAD duration of 177⫾145.8 days. VAD implantation reduced HOMA-IR (4.5⫾0.56 to 3.2⫾0.45, p⬍0.05). LDL, HDL and TG levels increased after VAD (p⬍0.05). Serum adiponectin (6.5⫾2.3 ug/ml in con vs 13.3⫾11.2 ug/ml in HF, p⫽0.02) was increased in HF compared to control. Serum adiponectin reduced after VAD implantation (7.5⫾4.4 ug/ml after VAD, p⬍0.05). Adiponectin expression in adipose tissue decreased after VAD implantation (p⬍0.03). In the myocardium, there was no change in adiponectin but expression of adiponectin receptors was lower in HF and normalized after VAD implantation (both p⬍0.05). In skeletal muscle, AdipoR2 expression decreased after VAD implantation (p⬍0.05). HF was associated with reduced adipocyte cross sectional area (1582.8⫾979.8 um2 vs 210.0⫾184.7 um2) and increased macrophage infiltration (p⬍0.01). VAD implantation tend to reduce macrophage infiltration.
Abstracts Conclusions: Our data demonstrate adiponectin resistance in patients with HF and correction of systemic and local changes in adipose tissue and myocardium after mechanical unloading of the failing heart. These findings suggest a role of adipose tissue and its signaling molecules in the pathogenesis of advanced HF. 466 Ventricular Assist Device Implantation Corrects Systemic and Peripheral Impairment of Growth Hormone/Insulin-Like Growth Factor-1 Signaling in Patients with Advanced Heart Failure A. Chokshi,1 M. Chew,1 R.S. Khan,1 F. Cheema,2 M. Jones,1 H. Takayama,2 Y. Naka,2 D. Mancini,1 P.C. Schulze.1 1 Cardiology/Medicine, Columbia University Medical Center, New York, NY; 2Cardiothoracic Surgery, Columbia University Medical Center, New York, NY. Purpose: Patients with advanced heart failure (HF) develop muscle atrophy and dysfunction which has been linked to impaired growth hormone (GH)/insulin-like growth factor (IGF)-1 axis signaling and insulin resistance. We hypothesized that implantation of a ventricular assist device (VAD) will reverse GH/IGF-1 axis dysfunction in HF. Methods and Materials: Clinical data were obtained from medical records. Serum and myocardial tissue was obtained from controls and patients with HF undergoing VAD implantation and explantation. Rectus muscle tissue was obtained during VAD surgery. Serum levels of GH, IGF-1 and IGFBP-3 were measured by ELISA. Skeletal muscle mRNA expression was analyzed by RT-PCR. Grip strength measurements were performed serially. Results: Controls had a mean age of 46⫾3.8 yrs and BMI of 25.7⫾0.9 kg/m2. HF patients had a mean age of 55⫾13.4 yrs, ejection fraction of 18⫾5.5% and VAD duration of 177⫾145.8 days. Serum GH increased (647⫾382.2 pg/ml vs 1370.9⫾254.3 pg/ml in HF, p⫽0.15) while IGF-1 and IGFBP-3 decreased in HF (5867.7⫾1299.3 pg/ml vs 786.3⫾369.4 pg/ml in HF, p⬍0.05; 2912.6⫾326.6 ng/ml in con vs 1711.5⫾188.1 ng/ml in HF, p⬍0.05). After VAD, IGF-1 levels increased 4-fold (2678.2⫾750.9 pg/ml, p⬍0.05) and IGFBP-3 increased mildly (2085.5⫾205.4 pg/ml, p⫽0.14), without changes in elevated levels of GH. After mechanical unloading, local skeletal muscle tissue expression of IGF-1 and IGFBP-3 increased 35-fold and 6-fold (both p⬍0.05), and cardiac expression of IGF-1 increased 3-fold (p⬍0.05). Grip strength improved by 15% on VAD support (p⬍0.05). Conclusions: Our data demonstrate that hemodynamic improvement through VAD support leads to correction of growth hormone resistance, increased tissue expression of IGF-1 in skeletal muscle and myocardium and increased serum levels of IGF-1 in patients with advanced HF. These findings show the reversibility of metabolic abnormalities of impaired systemic and local GH/IGF-1 signaling in patients with advanced HF. 467 Generally Accessible Echocardiographic Parameters of Left Heart Could Predict Right Heart Failure after Left Ventricular Assist Device Implantation T.S. Kato,1 M. Farr,1 M. Maurer,1 H. Akashi,2 K. Shahzad,1 N. Gukasyan,1 M. Deng,1 S. Iwata,1 S. Homma,1 H. Takayama,2 Y. Naka,2 C.P. Schulze,1 U. Jorde,1 D. Mancini.1 1Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY; 2Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY. Purpose: Right heart failure (RHF) after left ventricular assist device (LVAD) surgery is associated with high morbidity and mortality. Presurgery right heart evaluation by echocardiograms is often technically difficult. This study was designed to create a scoring system with echocardiogram (Echo) to assess the risk of RHF in LVAD recipients. Methods and Materials: We reviewed 111 patients (pts) who underwent LVAD surgery at Columbia University Medical Center after 2007. Pts with cardiogenic shock or post transplant graft failure were excluded. Echos within a month before the surgery were analyzed. RHF was
S159 defined as unexpected RVAD, inhaled nitric oxide (NO) ⬎48 hours, and/or inotropic support ⬎14 days. Results: 35 pts (32%) developed RHF; 15 with RVAD (14%), 17 with inotropes (15%) and 2 with NO (2%). Analyzable right heart images were obtainable from 56 pts (51%), while left heart images were obtained from all pts (100%). Thus, we focused on 2D left heart parameters. Left ventricular end-diastolic dimension (LVEDd) was smaller (62.7⫾10.2 vs. 73.2⫾12.7mm, p⬍0.0001), LV ejection fraction (LVEF) was greater (21.2⫾11.3 vs. 16.1⫾9.3%, p⫽0.0156), and the ratio of left atrium diameter (LAD) and LVEDd was greater (0.80⫾0.16 vs. 0.71⫾0.13, p⫽0.0037) in pts with RHF than those without RHF. The score was created based on ROC analysis of each parameter.[figure1]The sum of points ⬍2 excluded RHF with a sensitivity of 94% while ⱕ5 points determined RHF with a specificity of 92%.
Conclusions: Scoring system based on Echo-derived left heart parameter could predict RHF post LVAD surgery. Since this technique is not invasive or technically complicated, it may be utilized across centers. 468 Temporary Right Ventricular Support in Left Ventricular Assist Device Recipients A. Stepanenko,1 A. Loforte,2 N. Dranishnikov,1 E.V. Potapov,1 A. Montalto,2 M. Pasic,1 Y.-G. Weng,1 M. Dandel,1 H. Siniawski,1 M. Kukucka,1 T. Krabatsch,1 F. Musumeci,2 R. Hetzer.1 1Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany; 2Department of Cardiac Surgery and Transplantation, San Camillo Hospital, Rome, Italy. Purpose: Right ventricular failure (RVF) remains a major early postoperative complication after left ventricular assist device (LVAD) placement despite attempts to identify pts at risk. We describe temporary right ventricular assist device (RVAD) support with CentriMag (Levitronix, Waltham, Mass.) after LVAD placement. Methods and Materials: In 02/2009-10/2010, 27 consec. adult pts (4 women; age 51.3 ⫾10.1, range: 25-69 years) with preop. evidence of RVF (as defined by Pennsylvania University score ⬎55 and Michigan University score ⬎5) received a temporary CentriMag RVAD at the time of implantation of rotary LVAD at our institutions. Pts were suffering from idiopathic DCM (n⫽12, 44.4%), ischemic cardiomyopathy (n⫽10, 37.03%) and valvular cardiomyopathy (n⫽5, 18.5%). In 22 pts the RVAD was inserted at the time of LVAD placement (primary placement). In 5 CentriMag was implanted within 48 hours after LVAD placement (secondary placement). Results: During daily echo examinations progressive improvement of RV function was documented in 20 (74.07%) pts (n⫽17, primary placement; n⫽3, secondary placement). After an average of 13.2 postop. days pts were weaned from CentriMag by reducing RVAD flow by 10% every 12h, and after an average of 17.1 postoperative days the RVAD was successfully removed. All pts had good systolic function of the RV (EF 38 – 40%), CVP of 10-15 mmHg and stable LVAD flow. 3 (11.1%) pts required permanent support with an implantable centrifugal RVAD (HeartWare Inc., Miramar, Fla.). Five (18.5%) pts died on temporary RVAD support. Overall 18 (66.6%) pts were discharged home (n⫽17, permanent LVAD support; n⫽1, permanent BVAD support) and 3 (11.1%) received successful transplantation.
The Journal of Heart and Lung Transplantation, Vol 30, No 4S, April 2011
Conclusions: Combined HFMED and CF LVAD support led to cardiac improvement in half the patients. This approach to management after CF LVAD is safe and should encourage further study. 463 Increased Levels of Retinol Binding Protein 4 in Patients with Severe Heart Failure Correct after Hemodynamic Improvement through Ventricular Assist Device Placement N. Chavarria,1 F.H. Cheema,2 R. Khan,1 A. Chokshi,1 E. Collado,1 T. Kato,1 H. Takayama,2 Y. Naka,2 M. Farr,1 D.M. Mancini,1 P.C. Schulze.1 1Cardiology/Medicine, Columbia University Medical Center, New York, NY; 2Cardiothoracic Surgery, Columbia University Medical Center, New York, NY. Purpose: The syndrome of chronic heart failure (CHF) is associated with impaired glucose homeostasis and insulin resistance. Secretory products from adipocytes such as retinol binding protein 4 (RBP4), an adipose tissue-derived protein with prodiabetogenic effects, have been linked to the deterioration in glycemic control. The purpose of this study was to examine the relationship of RBP4 and insulin resistance in patients with advanced heart failure. Methods and Materials: Serum levels of RBP4, insulin and fasting glucose were assessed in patients with severe heart failure before and after left ventricular assist device (LVAD) implantation (n⫽62, mean age 57.9⫾12.6 years, mean ejection fraction 17.9 ⫾6.1%). Plasma levels of RBP4 were measured by ELISA and insulin resistance was assessed by the Homeostatic Model of Insulin Resistance (HOMA-IR). Results: At the time of LVAD implantation, RBP4 levels were significantly increased in severe heart failure patients compared to controls (21.8⫾8.8 vs. 16.0⫾3.9 mg/dL in controls; p⬍0.01) with normalization following LVAD removal (16.5⫾3.9mg/dL; p⬍0.05 vs. HF). RBP-4 levels correlated with concomitant increases in fasting glucose levels (R⫽0.3; p⬍0.05) and showed a trend towards correlation with HOMA-IR (R⫽0.242; p⫽0.08). Glucose homeostasis improved after LVAD with reduced HOMA-IR (4.05⫾2.6 vs. 2.6⫾1.9, p⫽0.007). Conclusions: Advanced heart failure is characterized by elevated levels of RBP4 which normalize after hemodynamic improvement through LVAD implantation. Circulating levels of RBP4 link adipocyte activation to impaired glucose homeostasis in advanced heart failure and suggest a novel role of adipose tissue in the pathogenesis of the syndrome of CHF. These findings underscore the role of systemic and local metabolic derangements in advanced heart failure and the potential reversibility of these abnormalities after correction of central hemodynamics through LVAD implantation. 464 Systolic Augmentation of Continuous Aortic Regurgitation: A Novel Marker of Increased Fractional Shortening and Flow in HeartMate II Supported Patients A. Agarwal, M. Padmalingam, R. Mohan, R. Banifatemi, J. Fontaine, S. Hankins, H. Eisen, J. Plehn. Division of Cardiology, Drexel University College of Medicine, Philadelphia, PA. Purpose: Prior observations suggest that continuous aortic regurgitation
(AR) is common following HeartMate II (HMII) placement but systolic augmentation of aortic regurgitation (SARA) has not been reported. We hypothesize that this finding is due to improved left ventricular systolic function and enhanced systolic aortic flow. Methods and Materials: We measured LV shortening(FS), mean arterial pressure(MAP), pump flow(PF), and SARA index(maximum aortic regurgitant systolic jet diameter-maximum aortic regurgitant diastolic jet diameter/maximum systolic aortic regurgitant jet diameter x 100%) in 29 adult HM II patients at baseline(0-30days post implant) and up to two years follow-up (mean 348.36⫾286.73 days). Significant AR was 2⫹ or greater. We also recorded aortic root dimension, aortic root index, pump speed and power, pulsatility index, and number of blood pressure (BP) medications at baseline and follow up (f/u). In the SARA⫹ and SARA-groups, the above parameters were compared at baseline and f/u. Results: Patients undergoing aortic valve repair at time of HMII placement or those with inadequate studies were excluded (n⫽7). SARA with continuous AR was noted in 3/22 pts at baseline and 11/22 (50%) at f/u. In the SARA⫹ group, the mean time to develop significant AR was 318⫾322.3 days. SARA index increased over seven fold from baseline to f/u (12.64⫾27.53vs.99.07⫾80.26,p⫽0.003), while FS did not increase significantly (10.9vs.15.5 cm,p⫽0.22). Change in FS correlated with change in SARA index(r⫽ 0.859). In the SARA⫹ group, PF increased (4.80⫾0.86vs.6.06 ⫾1.25 L/min,p⫽ 0.012). MAP was unchanged (92.82⫾11.77vs.92.91⫾22.91,p⫽NS). At f/u, the SARA⫹ group took more BP medications (0.9⫾0.7vs.1.6⫾0.69,p⫽0.02). In the SARA- group, PF (5.2vs.5.6), FS (6.1vs.9.4), MAP (91.4vs.89.6), and number of BP medications (0.6vs.0.8) did not increase significantly. Conclusions: SARA is a novel finding that reflects LV systolic recovery. This observation warrants closer evaluation of LV systolic and valvular function. 465 Mechanical Unloading through Ventricular Assist Device Implantation Corrects Adiponectin Resistance in Patients with Advanced Heart Failure R.S. Khan,1 A. Chokshi,1 M. Chew,1 S. Yu,1 P. Singh,1 F. Cheema,2 H. Takayama,2 Y. Naka,2 M.-J. Farr,1 D. Mancini,1 P.C. Schulze.1 1 Cardiology/Medicine, Columbia University Medical Center, New York, NY; 2Cardiothoracic Surgery, Columbia University Medical Center, New York, NY. Purpose: Heart failure is characterized by inflammation, insulin resistance (IR) and elevations in adipokines. Abnormal adiponectin receptor signaling has been linked to metabolic abnormalities in heart failure. We hypothesized that hemodynamic correction through implantation of a ventricular assist device (VAD) would reverse adipocyte activation and correct adiponectin signaling in patients with HF. Methods and Materials: Serum was collected from 18 subjects with HF before and after VAD implantation and 10 control subjects. Gene and protein expression of adiponectin in adipose tissue and their receptors in skeletal muscle and myocardium were assessed. Serum levels of insulin and adiponectin were measured by ELISA, and IR calculated using HOMA-IR. Results: The study population had a mean age of 55⫾13.4 years, ejection fraction of 18⫾5.5% and VAD duration of 177⫾145.8 days. VAD implantation reduced HOMA-IR (4.5⫾0.56 to 3.2⫾0.45, p⬍0.05). LDL, HDL and TG levels increased after VAD (p⬍0.05). Serum adiponectin (6.5⫾2.3 ug/ml in con vs 13.3⫾11.2 ug/ml in HF, p⫽0.02) was increased in HF compared to control. Serum adiponectin reduced after VAD implantation (7.5⫾4.4 ug/ml after VAD, p⬍0.05). Adiponectin expression in adipose tissue decreased after VAD implantation (p⬍0.03). In the myocardium, there was no change in adiponectin but expression of adiponectin receptors was lower in HF and normalized after VAD implantation (both p⬍0.05). In skeletal muscle, AdipoR2 expression decreased after VAD implantation (p⬍0.05). HF was associated with reduced adipocyte cross sectional area (1582.8⫾979.8 um2 vs 210.0⫾184.7 um2) and increased macrophage infiltration (p⬍0.01). VAD implantation tend to reduce macrophage infiltration.
Abstracts Conclusions: Our data demonstrate adiponectin resistance in patients with HF and correction of systemic and local changes in adipose tissue and myocardium after mechanical unloading of the failing heart. These findings suggest a role of adipose tissue and its signaling molecules in the pathogenesis of advanced HF. 466 Ventricular Assist Device Implantation Corrects Systemic and Peripheral Impairment of Growth Hormone/Insulin-Like Growth Factor-1 Signaling in Patients with Advanced Heart Failure A. Chokshi,1 M. Chew,1 R.S. Khan,1 F. Cheema,2 M. Jones,1 H. Takayama,2 Y. Naka,2 D. Mancini,1 P.C. Schulze.1 1 Cardiology/Medicine, Columbia University Medical Center, New York, NY; 2Cardiothoracic Surgery, Columbia University Medical Center, New York, NY. Purpose: Patients with advanced heart failure (HF) develop muscle atrophy and dysfunction which has been linked to impaired growth hormone (GH)/insulin-like growth factor (IGF)-1 axis signaling and insulin resistance. We hypothesized that implantation of a ventricular assist device (VAD) will reverse GH/IGF-1 axis dysfunction in HF. Methods and Materials: Clinical data were obtained from medical records. Serum and myocardial tissue was obtained from controls and patients with HF undergoing VAD implantation and explantation. Rectus muscle tissue was obtained during VAD surgery. Serum levels of GH, IGF-1 and IGFBP-3 were measured by ELISA. Skeletal muscle mRNA expression was analyzed by RT-PCR. Grip strength measurements were performed serially. Results: Controls had a mean age of 46⫾3.8 yrs and BMI of 25.7⫾0.9 kg/m2. HF patients had a mean age of 55⫾13.4 yrs, ejection fraction of 18⫾5.5% and VAD duration of 177⫾145.8 days. Serum GH increased (647⫾382.2 pg/ml vs 1370.9⫾254.3 pg/ml in HF, p⫽0.15) while IGF-1 and IGFBP-3 decreased in HF (5867.7⫾1299.3 pg/ml vs 786.3⫾369.4 pg/ml in HF, p⬍0.05; 2912.6⫾326.6 ng/ml in con vs 1711.5⫾188.1 ng/ml in HF, p⬍0.05). After VAD, IGF-1 levels increased 4-fold (2678.2⫾750.9 pg/ml, p⬍0.05) and IGFBP-3 increased mildly (2085.5⫾205.4 pg/ml, p⫽0.14), without changes in elevated levels of GH. After mechanical unloading, local skeletal muscle tissue expression of IGF-1 and IGFBP-3 increased 35-fold and 6-fold (both p⬍0.05), and cardiac expression of IGF-1 increased 3-fold (p⬍0.05). Grip strength improved by 15% on VAD support (p⬍0.05). Conclusions: Our data demonstrate that hemodynamic improvement through VAD support leads to correction of growth hormone resistance, increased tissue expression of IGF-1 in skeletal muscle and myocardium and increased serum levels of IGF-1 in patients with advanced HF. These findings show the reversibility of metabolic abnormalities of impaired systemic and local GH/IGF-1 signaling in patients with advanced HF. 467 Generally Accessible Echocardiographic Parameters of Left Heart Could Predict Right Heart Failure after Left Ventricular Assist Device Implantation T.S. Kato,1 M. Farr,1 M. Maurer,1 H. Akashi,2 K. Shahzad,1 N. Gukasyan,1 M. Deng,1 S. Iwata,1 S. Homma,1 H. Takayama,2 Y. Naka,2 C.P. Schulze,1 U. Jorde,1 D. Mancini.1 1Department of Medicine, Division of Cardiology, Columbia University Medical Center, New York, NY; 2Department of Surgery, Division of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY. Purpose: Right heart failure (RHF) after left ventricular assist device (LVAD) surgery is associated with high morbidity and mortality. Presurgery right heart evaluation by echocardiograms is often technically difficult. This study was designed to create a scoring system with echocardiogram (Echo) to assess the risk of RHF in LVAD recipients. Methods and Materials: We reviewed 111 patients (pts) who underwent LVAD surgery at Columbia University Medical Center after 2007. Pts with cardiogenic shock or post transplant graft failure were excluded. Echos within a month before the surgery were analyzed. RHF was
S159 defined as unexpected RVAD, inhaled nitric oxide (NO) ⬎48 hours, and/or inotropic support ⬎14 days. Results: 35 pts (32%) developed RHF; 15 with RVAD (14%), 17 with inotropes (15%) and 2 with NO (2%). Analyzable right heart images were obtainable from 56 pts (51%), while left heart images were obtained from all pts (100%). Thus, we focused on 2D left heart parameters. Left ventricular end-diastolic dimension (LVEDd) was smaller (62.7⫾10.2 vs. 73.2⫾12.7mm, p⬍0.0001), LV ejection fraction (LVEF) was greater (21.2⫾11.3 vs. 16.1⫾9.3%, p⫽0.0156), and the ratio of left atrium diameter (LAD) and LVEDd was greater (0.80⫾0.16 vs. 0.71⫾0.13, p⫽0.0037) in pts with RHF than those without RHF. The score was created based on ROC analysis of each parameter.[figure1]The sum of points ⬍2 excluded RHF with a sensitivity of 94% while ⱕ5 points determined RHF with a specificity of 92%.
Conclusions: Scoring system based on Echo-derived left heart parameter could predict RHF post LVAD surgery. Since this technique is not invasive or technically complicated, it may be utilized across centers. 468 Temporary Right Ventricular Support in Left Ventricular Assist Device Recipients A. Stepanenko,1 A. Loforte,2 N. Dranishnikov,1 E.V. Potapov,1 A. Montalto,2 M. Pasic,1 Y.-G. Weng,1 M. Dandel,1 H. Siniawski,1 M. Kukucka,1 T. Krabatsch,1 F. Musumeci,2 R. Hetzer.1 1Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany; 2Department of Cardiac Surgery and Transplantation, San Camillo Hospital, Rome, Italy. Purpose: Right ventricular failure (RVF) remains a major early postoperative complication after left ventricular assist device (LVAD) placement despite attempts to identify pts at risk. We describe temporary right ventricular assist device (RVAD) support with CentriMag (Levitronix, Waltham, Mass.) after LVAD placement. Methods and Materials: In 02/2009-10/2010, 27 consec. adult pts (4 women; age 51.3 ⫾10.1, range: 25-69 years) with preop. evidence of RVF (as defined by Pennsylvania University score ⬎55 and Michigan University score ⬎5) received a temporary CentriMag RVAD at the time of implantation of rotary LVAD at our institutions. Pts were suffering from idiopathic DCM (n⫽12, 44.4%), ischemic cardiomyopathy (n⫽10, 37.03%) and valvular cardiomyopathy (n⫽5, 18.5%). In 22 pts the RVAD was inserted at the time of LVAD placement (primary placement). In 5 CentriMag was implanted within 48 hours after LVAD placement (secondary placement). Results: During daily echo examinations progressive improvement of RV function was documented in 20 (74.07%) pts (n⫽17, primary placement; n⫽3, secondary placement). After an average of 13.2 postop. days pts were weaned from CentriMag by reducing RVAD flow by 10% every 12h, and after an average of 17.1 postoperative days the RVAD was successfully removed. All pts had good systolic function of the RV (EF 38 – 40%), CVP of 10-15 mmHg and stable LVAD flow. 3 (11.1%) pts required permanent support with an implantable centrifugal RVAD (HeartWare Inc., Miramar, Fla.). Five (18.5%) pts died on temporary RVAD support. Overall 18 (66.6%) pts were discharged home (n⫽17, permanent LVAD support; n⫽1, permanent BVAD support) and 3 (11.1%) received successful transplantation.