- Email: [email protected]
572: Post-Transplant Outcome of Elective vs. LVAD vs. Urgent Patients Undergoing Cardiac Transplantation
S264
Abstracts
The Journal of Heart and Lung Transplantation February 2009
CI 4.4% - 8.1%) at 5 and 8 years post-transplant respectively. Diabetic patients (p⫽0.03) and those who received peri-operative haemofiltration (p⫽0.01) were significantly more likely to receive long-term RRT, and there was variation between heart transplant centres (p⫽0.009). Patient survival on dialysis was 87% (95% CI 73% - 94%) at one-year, compared to a one-year national survival rate of 91% for patients aged under 65 receiving dialysis. Patients who were younger when they started dialysis were significantly more likely to receive a kidney transplant (p⬍0.001), as were patients with an original diagnosis of non-ischemic cardiomyopathy (p⫽0.02). All nine patients who received a kidney transplant were alive 2 years later. Conclusions: The incidence of advanced CKD requiring RRT increased with time post-transplant and an estimated 2.5% of patients received a kidney transplant within 10 years of their heart transplant. Survival on dialysis was similar to that of the general UK dialysis population.
570 Pre-Transplant FEV1/FVC but Not FEV1 Alone by Pulmonary Function Testing Predicts Poor Outcome after Heart Transplantation: The Bane of COPD J. Patel1, E. Shao1, J. Patel1, M. Kawano1, K. Kiyosaki1, A. Ankrom1, M. Kittleson1, J. Moriguchi1, A. Ardehali1, J. Kobashigawa1 1David Geffen School of Medicine at UCLA, Los Angeles, CA; 2David Geffen School of Medicine at UCLA, Los Angeles, CA Purpose: Significant chronic obstructive pulmonary disease (COPD) is a relative contraindication to heart transplant. However, the exact criteria for COPD have not been established. Pulmonary function tests (PFTs) reflect the degree of the pulmonary pathology and traditionally, FEV1⬍50% predicted and an FEV1/FVC ratio⬍70% define COPD. We examined whether these pretransplant PFT abnormalities were associated with poor outcomes following heart transplant. Methods and Materials: Between 1994-2008, 415 patients with complete pretransplant PFT data were examined. 91 patients had FEV1/FVC⬍70%, 39 patients had FEV1⬍50% predicted and the remaining 324 patients as controls. The following outcomes were assessed: 1-year rejection, 5-year survival, 5-year cardiac allograft vasculopathy (CAV), and 5-year non-fatal major adverse cardiac events (NF-MACE; myocardial infarction, heart failure, percutaneous intervention, pacemaker, stroke, new peripheral vascular disease). Results: Patients with FEV1⬍50% predicted had no difference in the incidence of rejection, survival, CAV, or NF-MACE compared with patients with higher FEV1. However, patients with FEV1/FVC⬍70% had significantly lower 5-year survival, lower freedom from NF-MACE and a trend towards lower freedom from CAV (Table). Patients with FEV1/FV⬍70% had more pulmonary infections (68% vs 15%, p⫽0.003) and a higher incidence of fatal pulmonary infections (8% vs 1%; P⬍0.001). Conclusions: Pretransplant FEV1/FVC⬍70% but not FEV1⬍50% predicted is a marker for poor outcomes after heart transplantation. This suggests that the FEV1/FVC ratio, but not the FEV1, may be used as a contraindication in the transplant evaluation process.
Outcomes: COPD (FEV1/FVC < 70%) vs. Control
5-Year 5-Year 5-Year 1-Year
Survival Freedom from NF-MACE Freedom from CAV Freedom from Rejection
COPD (Nⴝ91)
Control (Nⴝ324)
P-Value
63(69.2%) 80(87.9%) 70(76.9%) 84(92.3%)
267(82.4%) 310(95.7%) 269(83.0%) 294(90.7%)
0.006 0.002 0.06 0.68
571 Prevalence and Severity of Renal Dysfunction among 1059 Heart Transplant Patients According to Criteria Based on Serum Creatinine and Estimated Glomerular Filtration Rate: A Cross-Sectional Study M.G. Crespo-Leiro1, J.F. Delgado2, M.J. Paniagua1, L. Almenar3, L. Martinez-Doltz3, F. Gonzalez-Vilchez4, M.A. Gomez-Sanchez2, J. Fernandez-Yanez5, B. Diaz-Molina6, E. Roig7, J.M. Arizon8, L. Pulpon9, I. Garrido10, L. de la Fuente11, V. Brossa12, T. Blasco13, N. Manito14, J. Muniz1 1Complejo Hospitalario Universitario Juan Canalejo, La Corun ˜ a, Spain; 2Hospital 12 de Octubre, Madrid, Spain; 3Hospital La Fe, Valencia, Spain; 4 Hospital Marques de Valdecilla, Santander, Spain; 5Hospital Gregorio Maran ˜ on, Madrid, Spain; 6Hospital Central de Asturias, Oviedo, Spain; 7Hospital Clinic I Provincial, Barcelona, Spain; 8 Hospital Reina Sofia, Cordoba, Spain; 9Clinica Puerta de Hierro, Madrid, Spain; 10Hospital Universitario Virgen de la Arrixaca, Murcia, Spain; 11Hospital Clı´nico de Valladolid, Valladolid, Spain, 12 Hospital Santa Creu I Sant Pau, Barcelona, Spain; 13Hospital Miguel Servet, Zaragoza, Spain; 14Hospital de Bellvitge, Barcelona, Spain Purpose: Renal dysfunction (RD) is a major complication after heart transplantation (HT), but its prevalence may have been modified by changes in immunosuppressive protocols in recent years. This study aimed to determine a) the current prevalence of different levels of RD severity among HT patients according to criteria based on serum creatinine and estimated glomerular filtration rate, and b) the dependence of these prevalences on time post-HT. Methods and Materials: A multicentre cross-sectional observational study was carried out that aimed to include all adult first HT patients attended between November 2007 and March 2008 in 14 Spanish HT centres. RD was classified as absent-or-mild (AoM), moderate (M) or severe (S) using two criteria: serum creatinine (SCr), with cut-offs of 1.6 and 2.5 mg/dL (SCr-RD); and glomerular filtration rate (GFR) as estimated using the MDRD equation, with cut-offs of 60 and 30 mL/min/1.73 m2 (GFR-RD). Results: During the study period our centres attended 1065 postfirst-HT patients aged 59.1 ⫾ 12.5 years (82.3% men), and evaluated the renal function of 1059 a mean 6.7 years after HT (range 1 month to 22.3 years; first, second and third quartiles (Q1, Q2, Q3) 2.7, 6.2 and 9.5 years, respectively). Among the 1059 included in the study, SCr-RD grade was AoM in 70%, M in 26%, and S in 4%. GFR-RD grade was AoM in 40%, M in 53%, and S in 6%. Among patients evaluated at times ⬍ Q1, Q1 to Q2, Q2 to Q3, and ⬎ Q3, the percentages assigned SCr- and GFR-RD grades of AoM, M and S (in that order) were as follows: ⬍ Q1. SCr-RD: 76%, 22%, 2%. GFR-RD: 49%, 48%, 3%. Q1 to Q2. SCr-RD: 76%, 23%, 1%. GFR-RD: 40%, 58%, 2%. Q2 to Q3. SCr-RD: 71%, 24%, 5%. GFR-RD: 39%, 55%, 6%. Q3 to Q4. SCr-RD: 59%, 33%, 8%. GFR-RD: 33%, 54%, 13%. Conclusions: Some 60% of HT patients have moderate or severe RD. The prevalence of RD increases with time post-HT. Using conventional cut-offs, serum creatinine grades RD less severely than does MDRD-estimated GFR. 572 Post-Transplant Outcome of Elective vs. LVAD vs. Urgent Patients Undergoing Cardiac Transplantation D. Zimpfer, S. Mahr, A. Aliabadi, M. Groemmer, D. Dunkler, S. Sandner, G. Wieselthaler, E. Wolner, M. Grimm, A. Zuckermann Medical University Vienna, Vienna, Austria Purpose: This study was designed to determine the post-transplant outcome of elective, LVAD and urgent patients undergoing cardiac transplantation.
The Journal of Heart and Lung Transplantation Volume 28, Number 2S
Methods and Materials: The post-transplant outcome of 485 (82%) elective, 64 (11%) LVAD (DeBakey, Duraheart, Heartware LVAD) and 43 (7%) urgent patients (HU) undergoing cardiac transplantation between January 1998 and May 2008 was retrospectively analyzed. Survival, incidence of rejection, severe infections, CMV-disease and graft vasculopathy (CAV) were compared. All patients received immunosuppressive quadruple therapy consisting of thymoglobuline, Tac/Cyclo⫹MMF/Evl and low dose steroids. Kaplan-Meier analysis was performed to test differences between the groups. Results: Patients in the three groups were comparable with regard to primary disease. Urgent patients were younger (42⫾16yrs) than elective (52⫾13yrs) and LVAD (50⫾11yrs) patients (p⬍.001). Actuarial survival of elective (80%, 75%, 72%), LVAD (84%, 77%, 71%) and HU (81%, 78%, 71%) patients was comparable 1, 3 and 5 years post-transplant (log-rank .671). Furthermore, freedom from rejection episodes (elective: 91%, 90%, 90%, LVAD: 90%, 90%, 90%, HU: 93%, 93%, 93%; log-rank .991), severe infections (elective: 73%, 68%, 67%, LVAD: 84%, 82%, 82, HU: 73%, 73%, 70%; log-rank .118), CMV disease (elective: 91%, 90%, 90%, LVAD: 92%, 92%, 92%, HU: 86%, 86%, 86%; log-rank .415) and CAV (elective: 97%, 92%, 85%, LVAD: 96%, 89%, 83%, HU: 94%, 82%, 82%; log-rank .317) was comparable between elective, LVAD and HU patients 1, 3, and 5 years post-transplant respectively. Conclusions: Despite the increased risk of LVAD and urgent patients post-transplant outcome is excellent and compares to elective patients. The low incidence of rejections and CAV underlines the importance of induction therapy and individualized immunosuppression. 573 Normalization of Fixed Pulmonary Hypertension in Severe Heart Failure Patients with Placement of Left Ventricular Assist Device R. Zolty1, T. Vittorio1, B. Lowes2, S. Shakar2, A. Brieke2, A. Cannon2, J. Cleveland2, D. D’Alessandro3, D. Goldstein3, S. Maybaum3 1Albert Einstein College of Medicine, Bronx, NY; 2 University of Colorado Health Sciences Center, Aurora, CO; 3 Montefiore Medical Center, Bronx, NY Purpose: Fixed pulmonary hypertension in severe heart failure (HF) patients is an absolute contraindication to cardiac transplantation. The purpose of this study was to evaluate the effect of left ventricular assist device (LVAD) on pulmonary artery pressures and pulmonary vascular resistance (PVR) in patients with severe HF and fixed pulmonary hypertension non-responsive to pulmonary vasodilators and/or inotropic agents. Fixed pulmonary hypertension is defined as elevated pulmonary pressures, with a trans-pulmonary gradient ⬎15mmHg, Pulmonary Vascular Resistance (PVR) ⬎5mmHg and PA diastolic-wedge gradient⬎7mmHg, not reversible with pharmacologic agents. Methods and Materials: 12 patients with severe HF (8 non-ischemic, 4 ischemic cardiomyopathy), left ventricular ejection fraction ⬍25% and fixed pulmonary hypertension (PA systolic 66⫾7 mmHg and PVR 7.6⫾0.7 WU) underwent placement of LVAD. These patients were prospectively studied for reassessment of their hemodynamics and pulmonary artery pressures at 1 to 3 months post LVAD implantation. Results: The placement of LVAD (8 HM XVE, 4 HM II) resulted in statistical improvement of pulmonary pressures and PVR . Subsequently, all these patients were successfully transplanted with no development of RV failure after transplantation. Conclusions: Patients with severe HF and fixed pulmonary hypertension may benefit from LVAD implantation with normalization of their pulmonary pressures and may therefore subsequently be listed for orthotopic heart transplantation.
Abstracts
S265
Pulmonary Arety Pressures Improvement After Placement of LVAD Devices in 12 Patients with Fixed Pulmonary Hypertension PA PA mean Wedge Cardiac PVR systolic diastolic PA Mean Output (Wood (mmHg) (mmHg) (mmHg) Pressure (L/min) Units) (mmHg) Baseline 66⫾7 Post LVAD 36⫾2 placement P-value 0.0187* (compared to baseline)
36⫾1 14⫾4
48⫾2 23⫾2
24⫾1 13⫾2
3.1⫾0.1 7.6⫾0.7 5⫾0.6 2.2⫾0.2
0.0035*
0.0023*
0.0155*
0.028*
0.0023*
574 Sildenafil or Bosentan in Patients Considered Inelegible for Heart Transplantation Because of Severe Pulmonary Hypertension M. Farrero, F. Perez-Villa, A. Arias, A. Sionis, A. Castel, E. Roig Thorax Institut. Hospital Clinic., Barcelona, Spain Purpose: Elevated pulmonary vascular resistance (PVR) is associated to an increase in mortality in the early post-heart transplant period, mainly due to right ventricle dysfunction. This study aims to assess the effectiveness of both sildenafil and bosentan in decreasing the PVR in a group of patients initially considered ineligible for heart transplantation because of severe pulmonary hypertension. Methods and Materials: Sixteen patients with end-stage congestive heart failure and severe pulmonary hypertension were prospectively included. These were randomly assigned to receive either bosentan (125 mg bid) or sildenafil (80 mg tid). A second right heart catheterization was performed after 16 weeks of therapy. Results: No significant differences were observed in the two group’s basal characteristics. The bosentan group (n⫽7) had a basal transpulmonary gradient (TPG) of 21 ⫾6 mmHg that was reduced to 10 ⫾ 7 (p⫽0.005) during the treatment. Also the pulmonary vascular resistance decreased from 5.6 ⫾2.4 Wood units to 2.2 ⫾ 1.5 (p⫽0.003). The sildenafil group (n⫽7) showed a non significative trend towards RVP reduction (4.8 ⫾1.5 vs. 3.29 ⫾1.1; p⫽0,053) and TPG decrease (21 ⫾4 vs. 19 ⫾6; p⫽NS). TPG reduction was greater with bosentan (10.5 ⫾5 vs. 4.5 ⫾2mmHg, bosentan vs sildenafil; p⫽0.04). Treatment was stopped in 1 patient of each group due to intolerance. After treatment, 8 patients (5 bosentan, 3 sildenafil) were listed for heart transplantation and 6 of them (4 bosentan, 2 sildenafil) have already been transplanted successfully. Conclusions: Bosentan and sildenafil reduce RVP in patients considered ineligible for heart transplantation due to pulmonary hypertension, allowing them to be transplanted with good results. In our study, bosentan showed to be more effective than sildenafil in decreasing TPG and PVR. 575 Prognostic Value of Right Ventricular Dysfunction and Pulmonary Artery Hypertension Parameters for Risk Stratification of Patients with Heart Failure J.M. Barcelo, J. Segovia, M. Gomez-Bueno, P. Garcia-Pavia, M. Cobo, E. Sufrate, J. Mirelis, L. Alonso-Pulpon Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain Purpose: It is well established that the right ventricular dysfunction (RVD) is a powerful predictor of mortality in patients with heart failure. However, the additive prognostic value of RVD and pulmonary artery hypertension (PAH) is not well known. The aim of this study was to evaluate multiple RVD and PAH parameters that allowed an easy risk stratification of patients with symptomatic heart failure
Abstracts
The Journal of Heart and Lung Transplantation February 2009
CI 4.4% - 8.1%) at 5 and 8 years post-transplant respectively. Diabetic patients (p⫽0.03) and those who received peri-operative haemofiltration (p⫽0.01) were significantly more likely to receive long-term RRT, and there was variation between heart transplant centres (p⫽0.009). Patient survival on dialysis was 87% (95% CI 73% - 94%) at one-year, compared to a one-year national survival rate of 91% for patients aged under 65 receiving dialysis. Patients who were younger when they started dialysis were significantly more likely to receive a kidney transplant (p⬍0.001), as were patients with an original diagnosis of non-ischemic cardiomyopathy (p⫽0.02). All nine patients who received a kidney transplant were alive 2 years later. Conclusions: The incidence of advanced CKD requiring RRT increased with time post-transplant and an estimated 2.5% of patients received a kidney transplant within 10 years of their heart transplant. Survival on dialysis was similar to that of the general UK dialysis population.
570 Pre-Transplant FEV1/FVC but Not FEV1 Alone by Pulmonary Function Testing Predicts Poor Outcome after Heart Transplantation: The Bane of COPD J. Patel1, E. Shao1, J. Patel1, M. Kawano1, K. Kiyosaki1, A. Ankrom1, M. Kittleson1, J. Moriguchi1, A. Ardehali1, J. Kobashigawa1 1David Geffen School of Medicine at UCLA, Los Angeles, CA; 2David Geffen School of Medicine at UCLA, Los Angeles, CA Purpose: Significant chronic obstructive pulmonary disease (COPD) is a relative contraindication to heart transplant. However, the exact criteria for COPD have not been established. Pulmonary function tests (PFTs) reflect the degree of the pulmonary pathology and traditionally, FEV1⬍50% predicted and an FEV1/FVC ratio⬍70% define COPD. We examined whether these pretransplant PFT abnormalities were associated with poor outcomes following heart transplant. Methods and Materials: Between 1994-2008, 415 patients with complete pretransplant PFT data were examined. 91 patients had FEV1/FVC⬍70%, 39 patients had FEV1⬍50% predicted and the remaining 324 patients as controls. The following outcomes were assessed: 1-year rejection, 5-year survival, 5-year cardiac allograft vasculopathy (CAV), and 5-year non-fatal major adverse cardiac events (NF-MACE; myocardial infarction, heart failure, percutaneous intervention, pacemaker, stroke, new peripheral vascular disease). Results: Patients with FEV1⬍50% predicted had no difference in the incidence of rejection, survival, CAV, or NF-MACE compared with patients with higher FEV1. However, patients with FEV1/FVC⬍70% had significantly lower 5-year survival, lower freedom from NF-MACE and a trend towards lower freedom from CAV (Table). Patients with FEV1/FV⬍70% had more pulmonary infections (68% vs 15%, p⫽0.003) and a higher incidence of fatal pulmonary infections (8% vs 1%; P⬍0.001). Conclusions: Pretransplant FEV1/FVC⬍70% but not FEV1⬍50% predicted is a marker for poor outcomes after heart transplantation. This suggests that the FEV1/FVC ratio, but not the FEV1, may be used as a contraindication in the transplant evaluation process.
Outcomes: COPD (FEV1/FVC < 70%) vs. Control
5-Year 5-Year 5-Year 1-Year
Survival Freedom from NF-MACE Freedom from CAV Freedom from Rejection
COPD (Nⴝ91)
Control (Nⴝ324)
P-Value
63(69.2%) 80(87.9%) 70(76.9%) 84(92.3%)
267(82.4%) 310(95.7%) 269(83.0%) 294(90.7%)
0.006 0.002 0.06 0.68
571 Prevalence and Severity of Renal Dysfunction among 1059 Heart Transplant Patients According to Criteria Based on Serum Creatinine and Estimated Glomerular Filtration Rate: A Cross-Sectional Study M.G. Crespo-Leiro1, J.F. Delgado2, M.J. Paniagua1, L. Almenar3, L. Martinez-Doltz3, F. Gonzalez-Vilchez4, M.A. Gomez-Sanchez2, J. Fernandez-Yanez5, B. Diaz-Molina6, E. Roig7, J.M. Arizon8, L. Pulpon9, I. Garrido10, L. de la Fuente11, V. Brossa12, T. Blasco13, N. Manito14, J. Muniz1 1Complejo Hospitalario Universitario Juan Canalejo, La Corun ˜ a, Spain; 2Hospital 12 de Octubre, Madrid, Spain; 3Hospital La Fe, Valencia, Spain; 4 Hospital Marques de Valdecilla, Santander, Spain; 5Hospital Gregorio Maran ˜ on, Madrid, Spain; 6Hospital Central de Asturias, Oviedo, Spain; 7Hospital Clinic I Provincial, Barcelona, Spain; 8 Hospital Reina Sofia, Cordoba, Spain; 9Clinica Puerta de Hierro, Madrid, Spain; 10Hospital Universitario Virgen de la Arrixaca, Murcia, Spain; 11Hospital Clı´nico de Valladolid, Valladolid, Spain, 12 Hospital Santa Creu I Sant Pau, Barcelona, Spain; 13Hospital Miguel Servet, Zaragoza, Spain; 14Hospital de Bellvitge, Barcelona, Spain Purpose: Renal dysfunction (RD) is a major complication after heart transplantation (HT), but its prevalence may have been modified by changes in immunosuppressive protocols in recent years. This study aimed to determine a) the current prevalence of different levels of RD severity among HT patients according to criteria based on serum creatinine and estimated glomerular filtration rate, and b) the dependence of these prevalences on time post-HT. Methods and Materials: A multicentre cross-sectional observational study was carried out that aimed to include all adult first HT patients attended between November 2007 and March 2008 in 14 Spanish HT centres. RD was classified as absent-or-mild (AoM), moderate (M) or severe (S) using two criteria: serum creatinine (SCr), with cut-offs of 1.6 and 2.5 mg/dL (SCr-RD); and glomerular filtration rate (GFR) as estimated using the MDRD equation, with cut-offs of 60 and 30 mL/min/1.73 m2 (GFR-RD). Results: During the study period our centres attended 1065 postfirst-HT patients aged 59.1 ⫾ 12.5 years (82.3% men), and evaluated the renal function of 1059 a mean 6.7 years after HT (range 1 month to 22.3 years; first, second and third quartiles (Q1, Q2, Q3) 2.7, 6.2 and 9.5 years, respectively). Among the 1059 included in the study, SCr-RD grade was AoM in 70%, M in 26%, and S in 4%. GFR-RD grade was AoM in 40%, M in 53%, and S in 6%. Among patients evaluated at times ⬍ Q1, Q1 to Q2, Q2 to Q3, and ⬎ Q3, the percentages assigned SCr- and GFR-RD grades of AoM, M and S (in that order) were as follows: ⬍ Q1. SCr-RD: 76%, 22%, 2%. GFR-RD: 49%, 48%, 3%. Q1 to Q2. SCr-RD: 76%, 23%, 1%. GFR-RD: 40%, 58%, 2%. Q2 to Q3. SCr-RD: 71%, 24%, 5%. GFR-RD: 39%, 55%, 6%. Q3 to Q4. SCr-RD: 59%, 33%, 8%. GFR-RD: 33%, 54%, 13%. Conclusions: Some 60% of HT patients have moderate or severe RD. The prevalence of RD increases with time post-HT. Using conventional cut-offs, serum creatinine grades RD less severely than does MDRD-estimated GFR. 572 Post-Transplant Outcome of Elective vs. LVAD vs. Urgent Patients Undergoing Cardiac Transplantation D. Zimpfer, S. Mahr, A. Aliabadi, M. Groemmer, D. Dunkler, S. Sandner, G. Wieselthaler, E. Wolner, M. Grimm, A. Zuckermann Medical University Vienna, Vienna, Austria Purpose: This study was designed to determine the post-transplant outcome of elective, LVAD and urgent patients undergoing cardiac transplantation.
The Journal of Heart and Lung Transplantation Volume 28, Number 2S
Methods and Materials: The post-transplant outcome of 485 (82%) elective, 64 (11%) LVAD (DeBakey, Duraheart, Heartware LVAD) and 43 (7%) urgent patients (HU) undergoing cardiac transplantation between January 1998 and May 2008 was retrospectively analyzed. Survival, incidence of rejection, severe infections, CMV-disease and graft vasculopathy (CAV) were compared. All patients received immunosuppressive quadruple therapy consisting of thymoglobuline, Tac/Cyclo⫹MMF/Evl and low dose steroids. Kaplan-Meier analysis was performed to test differences between the groups. Results: Patients in the three groups were comparable with regard to primary disease. Urgent patients were younger (42⫾16yrs) than elective (52⫾13yrs) and LVAD (50⫾11yrs) patients (p⬍.001). Actuarial survival of elective (80%, 75%, 72%), LVAD (84%, 77%, 71%) and HU (81%, 78%, 71%) patients was comparable 1, 3 and 5 years post-transplant (log-rank .671). Furthermore, freedom from rejection episodes (elective: 91%, 90%, 90%, LVAD: 90%, 90%, 90%, HU: 93%, 93%, 93%; log-rank .991), severe infections (elective: 73%, 68%, 67%, LVAD: 84%, 82%, 82, HU: 73%, 73%, 70%; log-rank .118), CMV disease (elective: 91%, 90%, 90%, LVAD: 92%, 92%, 92%, HU: 86%, 86%, 86%; log-rank .415) and CAV (elective: 97%, 92%, 85%, LVAD: 96%, 89%, 83%, HU: 94%, 82%, 82%; log-rank .317) was comparable between elective, LVAD and HU patients 1, 3, and 5 years post-transplant respectively. Conclusions: Despite the increased risk of LVAD and urgent patients post-transplant outcome is excellent and compares to elective patients. The low incidence of rejections and CAV underlines the importance of induction therapy and individualized immunosuppression. 573 Normalization of Fixed Pulmonary Hypertension in Severe Heart Failure Patients with Placement of Left Ventricular Assist Device R. Zolty1, T. Vittorio1, B. Lowes2, S. Shakar2, A. Brieke2, A. Cannon2, J. Cleveland2, D. D’Alessandro3, D. Goldstein3, S. Maybaum3 1Albert Einstein College of Medicine, Bronx, NY; 2 University of Colorado Health Sciences Center, Aurora, CO; 3 Montefiore Medical Center, Bronx, NY Purpose: Fixed pulmonary hypertension in severe heart failure (HF) patients is an absolute contraindication to cardiac transplantation. The purpose of this study was to evaluate the effect of left ventricular assist device (LVAD) on pulmonary artery pressures and pulmonary vascular resistance (PVR) in patients with severe HF and fixed pulmonary hypertension non-responsive to pulmonary vasodilators and/or inotropic agents. Fixed pulmonary hypertension is defined as elevated pulmonary pressures, with a trans-pulmonary gradient ⬎15mmHg, Pulmonary Vascular Resistance (PVR) ⬎5mmHg and PA diastolic-wedge gradient⬎7mmHg, not reversible with pharmacologic agents. Methods and Materials: 12 patients with severe HF (8 non-ischemic, 4 ischemic cardiomyopathy), left ventricular ejection fraction ⬍25% and fixed pulmonary hypertension (PA systolic 66⫾7 mmHg and PVR 7.6⫾0.7 WU) underwent placement of LVAD. These patients were prospectively studied for reassessment of their hemodynamics and pulmonary artery pressures at 1 to 3 months post LVAD implantation. Results: The placement of LVAD (8 HM XVE, 4 HM II) resulted in statistical improvement of pulmonary pressures and PVR . Subsequently, all these patients were successfully transplanted with no development of RV failure after transplantation. Conclusions: Patients with severe HF and fixed pulmonary hypertension may benefit from LVAD implantation with normalization of their pulmonary pressures and may therefore subsequently be listed for orthotopic heart transplantation.
Abstracts
S265
Pulmonary Arety Pressures Improvement After Placement of LVAD Devices in 12 Patients with Fixed Pulmonary Hypertension PA PA mean Wedge Cardiac PVR systolic diastolic PA Mean Output (Wood (mmHg) (mmHg) (mmHg) Pressure (L/min) Units) (mmHg) Baseline 66⫾7 Post LVAD 36⫾2 placement P-value 0.0187* (compared to baseline)
36⫾1 14⫾4
48⫾2 23⫾2
24⫾1 13⫾2
3.1⫾0.1 7.6⫾0.7 5⫾0.6 2.2⫾0.2
0.0035*
0.0023*
0.0155*
0.028*
0.0023*
574 Sildenafil or Bosentan in Patients Considered Inelegible for Heart Transplantation Because of Severe Pulmonary Hypertension M. Farrero, F. Perez-Villa, A. Arias, A. Sionis, A. Castel, E. Roig Thorax Institut. Hospital Clinic., Barcelona, Spain Purpose: Elevated pulmonary vascular resistance (PVR) is associated to an increase in mortality in the early post-heart transplant period, mainly due to right ventricle dysfunction. This study aims to assess the effectiveness of both sildenafil and bosentan in decreasing the PVR in a group of patients initially considered ineligible for heart transplantation because of severe pulmonary hypertension. Methods and Materials: Sixteen patients with end-stage congestive heart failure and severe pulmonary hypertension were prospectively included. These were randomly assigned to receive either bosentan (125 mg bid) or sildenafil (80 mg tid). A second right heart catheterization was performed after 16 weeks of therapy. Results: No significant differences were observed in the two group’s basal characteristics. The bosentan group (n⫽7) had a basal transpulmonary gradient (TPG) of 21 ⫾6 mmHg that was reduced to 10 ⫾ 7 (p⫽0.005) during the treatment. Also the pulmonary vascular resistance decreased from 5.6 ⫾2.4 Wood units to 2.2 ⫾ 1.5 (p⫽0.003). The sildenafil group (n⫽7) showed a non significative trend towards RVP reduction (4.8 ⫾1.5 vs. 3.29 ⫾1.1; p⫽0,053) and TPG decrease (21 ⫾4 vs. 19 ⫾6; p⫽NS). TPG reduction was greater with bosentan (10.5 ⫾5 vs. 4.5 ⫾2mmHg, bosentan vs sildenafil; p⫽0.04). Treatment was stopped in 1 patient of each group due to intolerance. After treatment, 8 patients (5 bosentan, 3 sildenafil) were listed for heart transplantation and 6 of them (4 bosentan, 2 sildenafil) have already been transplanted successfully. Conclusions: Bosentan and sildenafil reduce RVP in patients considered ineligible for heart transplantation due to pulmonary hypertension, allowing them to be transplanted with good results. In our study, bosentan showed to be more effective than sildenafil in decreasing TPG and PVR. 575 Prognostic Value of Right Ventricular Dysfunction and Pulmonary Artery Hypertension Parameters for Risk Stratification of Patients with Heart Failure J.M. Barcelo, J. Segovia, M. Gomez-Bueno, P. Garcia-Pavia, M. Cobo, E. Sufrate, J. Mirelis, L. Alonso-Pulpon Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain Purpose: It is well established that the right ventricular dysfunction (RVD) is a powerful predictor of mortality in patients with heart failure. However, the additive prognostic value of RVD and pulmonary artery hypertension (PAH) is not well known. The aim of this study was to evaluate multiple RVD and PAH parameters that allowed an easy risk stratification of patients with symptomatic heart failure