568: Liberal Use of Tricuspid Valve Annuloplasty during Left Ventricular Assist Device Implantation Does Not Increase Perioperative Risk

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The Journal of Heart and Lung Transplantation, Vol 29, No 2S, February 2010

off-pump procedure. The inflow cannula draws blood from the LA and pumps blood via an outflow graft to the subclavian artery. We compared the adverse events associated with Synergy to a similar HeartMate II patient population. Results: 27 patients with baseline MAP 76 mmHg, PCWP 27 mmHg and CO 2.6 L/min were implanted with a Synergy device. Duration of support averaged 106 (6-281) days. Survival to discharge or transplantation was 93% (25/27). Hemodynamics, demographics and overall outcomes are similar to those reported for HeartMate II. The rates of adverse events (events/patient year) are summarized below:[table1]

HeartMate IIⴱ

CircuLite

Bleeding (re-op) Bleeding (transfusion) Ventricular arrhythmias Driveline/pocket infection Local infection (non-device) Sepsis Renal failure Stroke Embolism during pump exchange Spinal cord infarct TIA Other neurologic ⴱ

hemodynamical stabilization by IABP might contribute to improve postVAD outcomes.[figure1]

0-30 Days

⬎30 Days

0-30 (Days

⬎30 (Days)

2.62 1.05 1.57 0.52 0.52 0.52 0.52 0.52 0 0 0 0

0 0.42 0.21 0.21 0.84 0.21 0.42 0 0.21 0 0 0.21

4.41 8.33 2.55 0 3.63 1.77 1.47 0.89 0 0 0.2 0.29

0.06 0.85 0.45 0.45 0.64 0.39 0.08 0.08 0 0.02 0.08 0.14

Miller et al, NEJM 2007

Conclusions: Partial circulatory support with the Synergy device, which is less invasive and intended for a less sick population, appears to result in less adverse events as compared to HeartMate II. This device has the potential to expand the use of circulatory support to a large group of patients with severe medically refractory CHF. 566 Improved Outcomes after Ventricular Assist Device Implantation in Patients Requiring Intra-Aortic Balloon Pump S. Osaki,1 N.M. Edwards,1 M.R. Johnson,2 M.A. Murray,1 A.K. Proebstle,1 L. Lozonschi,1 T. Kohmoto.1 1University of Wisconsin School of Medicine and Public Health, Madison, WI; 2University of Wisconsin School of Medicine and Public Health, Madison, WI. Purpose: Recently a multicenter registry for ventricular assist device (VAD) support reported that cardiogenic shock requiring temporary circulatory support such as an intra-aortic balloon pump (IABP) was a significant risk factor for death after VAD therapy. To determine if the need for pre-operative IABP is a risk factor for post-VAD survival, we evaluated the outcomes since the inception of our multidisciplinary VAD and heart transplantation program. Methods and Materials: We retrospectively studied 89 consecutive VAD recipients between Aug 2003 and Sept 2009 in our center. The cohort was divided into the IABP (with IABP before VAD, n⫽31) and the non-IABP (without IABP before VAD, n⫽58) groups. Demographics and post-VAD implant survival were assessed. Results: Patient age, diagnosis, and cardiac function were similar between the groups. However, the patients with IABP had lower mean pulmonary arterial pressure (34 vs 41 mmHg, p⬍0.01) and a higher serum aspartate aminotransferase level (657 vs 62 U/L, p⬍0.01). The rate of biventricular support was similar between the groups (3/31 [10%] vs 4/58 [7%], p⫽0.80). Post-VAD implant survival at 30-day, 1-year and 3-year was 100%, 86% and 72% in the IABP group, and 95%, 74% and 69% in the non-IABP group (p⫽0.52, Figure). Conclusions: Our data demonstrates excellent short- and mid-term survival in both groups. The data does not support the notion that preoperative IABP support is associated with worse post VAD outcomes. In fact, despite higher prevalence of cardiogenic shock criteria, the IABP supported patients did not fare worse than patients without IABP support. Pre-VAD

567 Single-Center Experience Using the Heartmate II Left Ventricular Assist Device as a Bridge to Decision M. Toma,1 G.V. Gonzalez-Stawinski,2 D. Schmuhl,1 N.G. Smedira,2 R.C. Starling,1 M.M. Mountis.1 1The Cleveland Clinic Foundation, Cleveland, OH; 2The Cleveland Clinic Foundation, Cleveland, OH. Purpose: There is scant data regarding the outcomes of patients deemed Bridge to Decision (BTD) with a HeartMate II left ventricular assist device (LVAD). We sought to review the outcomes of patients who received a HM II LVAD as BTD. Methods and Materials: All patients who received a HM II LVAD between June 2006 and July 2009 were included in this analysis and followed for a mean period of 235 days. BTD was defined using the Interagency Registry for Mechanical Assisted Circulatory Support (INTERMACS) strategy at implant (BTT – likely, BTT – moderate likelihood, BTT – unlikely). We reviewed the factors precluding listing as BTT. Clinical outcomes at 30-days and end of follow-up were determined. Results: A total of 96 patients underwent implantation of HM II LVAD during the study period. The listing strategy was BTD in 34 pts (35%), BTT in 41 pts (43%), and DT in 21 pts (22%). Of the 34 pts listed as BTD, 24 (71%) were BTT-likely, 8 (24%) were BTT-moderate, and 2 (6%) were BTT-unlikely. Factors for BTD listing were: psychosocial issues (6), substance abuse (5), pulmonary hypertension (4), morbid obesity (3), history of malignancy (2), kidney dysfunction (1) and emergent implantation (4), and other (9). The 30-day and end of follow-up survival were 91% and 79%, respectively, for BTD; 95% and 83%, respectively, for BTT; and 86% and 52% for DT, respectively. Of those alive at the end of follow-up in the BTD group, 5 were transplanted, 4 were changed to BTT, 2 were changed to DT, and 16 remain listed as BTD. Conclusions: The BTD strategy is commonly used in patients undergoing LVAD support using the HM II LVAD and is associated with favorable clinical outcomes. The 30-day and end of follow-up survival for BTT listed patients and BTD (likely, moderately, and unlikely) were similar for both groups. Further, many BTD candidates became BTT patients. Future guidelines should incorporate BTD as an accepted category for patients receiving LVAD support. 568 Liberal Use of Tricuspid Valve Annuloplasty during Left Ventricular Assist Device Implantation Does Not Increase Perioperative Risk K. Krishan, S. Pinney, V. Ramjee, D. Adams, A. Anyanwu. Mount Sinai Medical Center, New York, NY. Purpose: Although patients undergoing left ventricular assist device (LVAD) surgery often have tricuspid regurgitation (TR), tricuspid valve repair (TVr) is not generally performed during because of fear of precipitating right ventricular failure or increasing morbidity. Persisting TR post-LVAD may however have significant mid-term implications, particularly in destination or recovery patients. We reviewed our experience to determine whether liberal use of TVr is associated with adverse outcomes. Methods and Materials: Retrospective review of 43 implantable LVADs

Abstracts

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performed in a single center between Jan 2008 and Sept 2009. TVr using Edwards MC 3 annuloplasty ring was performed if there was documented moderate or greater TR or severe annular dilatation. Results: TVr was performed in 30 patients. Compared to patients who did not have TVr, the age was similar (mean 52 vs. 50 yr), as was frequency of INTERMACS level 1 or 2 (43% vs 46%). Day 1 hemodynamics were also similar: mean central venous pressure (14 vs. 14 mmHg); mean pulmonary artery pressure (25 vs. 26 mmHg); as was day 1 bilirubin (3.7 vs. 4.0 mg/dL). Ten percent (3/30) patients with TVr had temporary right ventricular assist device support as compared to 15.4% (2/13) without. Median duration of mechanical ventilation (2 days) and inotropic support (5 days) was identical in both groups. Although median ICU stay was slightly higher with TVr (6.5 vs. 5 days), as a group these patients experienced a tendency to lower rates of post-operative bleeding, blood product transfusion and hospital length of stay. Hospital mortality was similar in both groups (TVr 16.6%, no TVr 15.4%). There have been no deaths on support after hospital discharge in either group (median days on support: 102; range 14-431). Conclusions: TVr can be applied during LVAD implantation without increase in perioperative risk. As there are theoretical benefits to eliminating TR, our data argue for a more liberal approach to TVr at time of LVAD implantation. 569 Effects of Piperacillin -Tazobactam Perioperative Pneumonia Prophylaxis on Outcomes in the First 30 days Post Lung Transplantation N. Marks, L. Singer, C. Chaparro, C. Chow, M. Hutcheon, T. Waddell, K. Yasufuku, A. Pierre, M. de Perrot, D. Munyal, J. Wang, S. Keshavjee, S. Husain. UHN, Toronto, ON, Canada. Purpose: The development of antibiotic resistant organisms is especially concerning in lung transplantation. We recently broadened our perioperative prophylaxis to more aggressively prophylax for peri-operative pneumonia. We chose Piperacillin-Tazobactam (P-T) based on known nosocomial bacterial flora. We evaluated the impact of P-T based strategy on patient exposure to antibiotics, ICU length of stay (LOS), and incidence of resistant (R) organisms to P-T within 30 days post-op. Methods and Materials: We retrospectively collected data on recipient BAL c&s, ICU LOS, and the duration of antibiotic usage in 53 recent consecutive recipients (September 4, 2008- May 16, 2009) and compared to a control group of 20 patients from a previous era (January 1, 2008- July 1, 2008). Empiric peri-operative antibiotic prophylaxis was P-T for 72h post-op ⫾ coverage of respiratory organisms in recipient or donor, except in 5 recipients who did not receive P-T. Those with CF or who died in 30 days were excluded. Results: Average duration of P-T was 10.7 days.[table1]There was a trend of decreased number and duration of antibiotic usage in the P-T group versus the control [see table 1]. ICU length of stay was decreased (median of 6 to 3.8d, p⫽0.0665), and there was no development of organism resistance to P-T. Percentage of positive BAL was 15% P-T vs 11% control. Conclusions: Appropriate peri-operative antimicrobial coverage remains an important consideration in the management of lung transplant recipients. Despite the theoretical risk of R organisms, we saw an overall decrease in the exposure to antibiotics and ICU stay. We did not observe the development of P-T R organisms. There was no change in the number of positive BAL, despite less antibioitc use in the P-T group.

Duration of Antibiotics Usage Per Patient Antibiotic 2nd Generation Cephalosporins 3rd Generation Cephalosporins Piperacillin/Tazobactam Fluroquinolones Vancomycin Carbapenems

Control (n⫽20) 4.75 3.4 10.5 6.4 11.3 9.3

Pip/tazo era (n⫽53) 0.2 1.4 9.7 4.7 3.8 3

570 Safety of EBV-DNA-Load Guided Pre-Emptive Reduction of Immunosuppression To Prevent PTLD E.A. Verschuuren,1 M.E. Erasmus,2 B.L. Rottier,3 G.D. Nossent,1 W. van der Bij.1 1University Medical Centre Groningen, Groningen, Netherlands; 2University Medical Centre Groningen, Groningen, Netherlands; 3University Medical Centre Groningen, Groningen, Netherlands. Purpose: Post transplant lymphoproliferative disorder (PTLD) is a devastating complication after transplantation. In our program immunosuppression (IS) is pre-emptively reduced based on Epstein-Barr viral load to prevent PTLD. We here describe our experience in our population transplanted between 2001 and 2009. All primary adult and pediatric, lung, heart-lung and lung-liver transplant patients with a survival over 2 months were included in this study. Methods and Materials: 196 EBV seropositive thoracic transplantations were performed and 159 patients were evaluated. 34 pts died within the hospital and 3 had their follow-up elsewhere. Follow-up was between 0.8 and 8.3 years. IS consisted of Basiliximab, Tacrolimus, Azathioprin (Aza) and prednisolone. If EBV DNA load in whole blood exceeded 10.000 copies/ml blood Aza was reduced and stopped in case of further rise in EBV DNA load. 10 patients with primary EBV infection are described. Kaplan-Meyer estimated survival was used to compare survival and development of BOS. Results: 159 EBV seropositive pts were analyzed in 3 groups. Group A, patients who remained EBV DNA negative (n⫽110). Group B, pts with detectable EBV DNA with stable IS (n⫽28) and group C, Pts with an EBV DNA load that required reduction of IS (n⫽21). Survival, BOS free survival and PTLD is shown in table 1. Both patients in group A died of PTLD whereas both patients in group C survived. 10 seronegative pts developed primary EBV infection. IS was reduced in all pts, 2 developed acute rejection. 5 died: 3 due to PTLD, 1 of lung carcinoma and 1 of BOS.[table1]

Table 1 Group

Survival

BOS free Survival

N of Pts

N of PTLD

A B C

84% 68% 80%

85% 80% 90%

159 28 21

2 — 2

Kaplan-Meyer estimated 8yrs results of EBV seropositive pts

Conclusions: IS reduction in EBV-seropositive recipients guided by EBV DNA load is not counterbalanced by excess mortality or an increase in BOS and thus a safe approach. IS reduction alone does not prevent PTLD in EBV mismatched lung transplant. 571 Activity of Colistin Against Filamentous Fungi Isolated from Lung Transplant Recipients G. Short,1 C. Rennison,1 K. Gould,1 A. Fisher.2 1Freeman Hospital, Newcastle upon Tyne, United Kingdom; 2Freeman Hospital, Newcastle upon Tyne, United Kingdom. Purpose: Whilst performing direct susceptibility tests on a Bronchoalveolar lavage from a lung recipient at time of transplant it was noted that although the plate was overgrown with Scedosorium apiospermum a zone of inhibition was noted around the colistin disc. Colistin is a polymixin antibiotic active against the bacterial cell membrane but not known to be active against fungi. We studied the antifungal activity of colistin against a range of fungi isolated from patients either listed for or having received lung transplants. Methods and Materials: Isolates of Scedosporium spp.(12) Geosmithia spp. (3) Paecilomyces spp(1) and Aspergillus sp(5) were collected from patients being assessed or having undergone lung transplantation including cystic fibrosis patients. The minimum inhibitory concentrations (MIC) of