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597: Use of Extracorporeal Membrane Oxygenation in Advanced Cardiogenic Shock Complicating an Acute Myocardial Infarction
The Journal of Heart and Lung Transplantation Volume 28, Number 2S
596 An Increasing Percentage of Orthotopic Heart Transplant Procedures in the United States Are Being Performed at Lower-Volume Centers J.B. Williams, C.A. Milano, E.M. Avikik, P.C. Kuo, T.N. Pappas, J.E. Scarborough Duke University Medical Center, Durham, NC Purpose: We have recently shown that lung transplant procedures in the United States are increasingly being performed at high-volume centers, and that a volume-outcomes relationship is emerging for this procedure. We sought to determine if the same phenomenon is occurring for heart transplantion. Methods and Materials: A retrospective analysis of all adult heart transplant procedures included in the Scientific Registry of Transplant Recipients for three consecutive time periods between 1999 and 2006 was performed. For each time period, centers were divided into two groups based on annual adult heart transplant volume (ⱕ19 per year ⫽ lower-volume, ⱖ 20 ⫽ higher-volume). Temporal analyses of center volume and outcomes (1-month and 1-year observed-to-expected (O:E) patient death ratios) were performed using chi square testing. Results: 13,191 adult heart transplant procedures were analyzed. The percentage of heart transplants being performed in lower-volume centers increased significantly from 42.9% in Period 1 to 52.3% in Period 3 (p ⬍ 0.0001), while the percentage being performed in higher-volume centers decreased over the same time period (from 57.1% in Period 1 to 47.3% in Period 3, p ⬍ 0.0001). In Period 1, the 1-month O:E patient death ratio for lower-volume centers was significantly greater than the 1-month ratio for higher-volume centers (1.25 vs 0.81, p ⫽ 0.005). By Period 3, however, this discrepancy in outcomes was no longer statistically signficant (1.09 vs 0.90, p ⫽ 0.32). Similar findings were observed for 1-year O:E patient death ratios. Conclusions: Unlike lung transplantation, heart transplant procedures in the United States are increasingly being performed at lower-volume centers. These temporal changes in center volume are associated with a progressive weakening in the robustness of the relationship between the center volume of heart transplantation and recipient outcomes. Further investigation is warranted to determine why lung and heart transplantation have divergent regionalization patterns. 597 Use of Extracorporeal Membrane Oxygenation in Advanced Cardiogenic Shock Complicating an Acute Myocardial Infarction C. Bermudez, L. Wei, F. Avila, Y. Toyoda, M. Siegenthaler, C. Spadaccio, S. Mulukutla, J. Schindler, M. Refaat, R. Kormos University of Pittsburgh Medical Center, Pittsburgh, PA Purpose: Extracorporeal membrane oxygenation (ECMO) confers full hemodynamic support in patients with shock and severe hemodynamic involvement after an acute myocardial infarction (CS-AMI), with the advantage of implantation simplicity. We reviewed our institutional experience and outcomes in this population. Methods and Materials: 88 patients (pts) with CS-AMI evaluated for surgical consideration between June 2003 and Februray 2008 were analyzed retrospectively .22 pts required ECMO for stabilization and 66 pts underwent primary surgical revascularization (CABG). Results: 12 pts in the ECMO group had previous cardiac arrest ,21 were on high dose inotropes,19 had an intraaortic balloon (IABP) and 16 were on mechanical ventilation .Percutaneous approach was used in 20 pts with femoral access . The average time of support was 68.1 h (range 3-240). Eight pts (36%) were successfully weaned from ECMO.Of these 5 underwent CABG and 3 had PCI alone prior to ECMO removal. 11/22 patients were bridged to a ventricular assist device (VAD) with subsequent transplant (5 patients), recovery (1 patient) or died on VAD support (5 patients).13/22 pts (59%) survived to
Abstracts
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discharge.Of the CABG group 33 pts were on inotropes and 58 pts had IABP placed preoperatively.The majority of the pts, 42 (64%) underwent revascularization after 24 hours of diagnosis (1-7 days) and 13 pts within 24 hours. The hospital mortality on the entire CABG group was 28.8 % vs 41 % in the ECMO series (p⫽ 0.3). Kaplan Meier Survival curve is presented. Conclusions: Use of ECMO in selected patients with severely decompensated CS-AMI allow patient recovery from initial insult and facilitates an individual treatement strategy with improved short and mid term survival.
598 Physiological Changes Following Placement of Continuous Flow and Pulsatile Flow Left Ventricular Assist Devices B.A. Boilson1, J.A. Schirger1, B. Sareyyupoglu2, I. Penev2, C.G.A. McGregor2, L.C. Durham2, R.C. Daly2, B.S. Edwards1, S.J. Park2 1 Mayo Clinic, Rochester, MN; 2Mayo Clinic, Rochester, MN Purpose: Left ventricular assist devices (LVADs) are being used increasingly as a bridge to transplantation and also as a viable permanent option for patients unsuitable for transplantation. The bulk of data available on long term outcome with LVADs is based on the pulsatile flow (PU) device, but devices that deliver continuous blood flow (CF) are expected to be more durable. The aim of this study was to investigate physiologic effects of PU versus CFdesigns on physiologic changes post LVAD implantation. Methods and Materials: All patients who underwent LVAD implantation at out institution between May 2003 and July 2008 were evaluated. Baseline functional, echocardiographic, laboratory and cardiac catheterization data were recorded and compared with data at followup. Results: A total of 57 patients were studied. 42 patients underwent implantation of a CF device and 15 received a PU device. Comparison between device types revealed no significant differences in changes in hemodynamic or echocardiographic parameter changes following implantation of CF or PU devices. Conclusions: Both PU and CF devices are effective in offloading the left ventricle with reduction in LVIDD, PA pressures and MR severity. This is accompanied by an expected reduction in serum BNP. Numbers of pulsatile devices implanted were small which may account for lack of significance of some changes in this group compared to the CF group, and therefore extrapolations regarding relative efficacy are limited, but there is a suggestion that CF devices may be more efficacious in LV offloading. Finally, SVR increased following LVAD implantation, unlike
596 An Increasing Percentage of Orthotopic Heart Transplant Procedures in the United States Are Being Performed at Lower-Volume Centers J.B. Williams, C.A. Milano, E.M. Avikik, P.C. Kuo, T.N. Pappas, J.E. Scarborough Duke University Medical Center, Durham, NC Purpose: We have recently shown that lung transplant procedures in the United States are increasingly being performed at high-volume centers, and that a volume-outcomes relationship is emerging for this procedure. We sought to determine if the same phenomenon is occurring for heart transplantion. Methods and Materials: A retrospective analysis of all adult heart transplant procedures included in the Scientific Registry of Transplant Recipients for three consecutive time periods between 1999 and 2006 was performed. For each time period, centers were divided into two groups based on annual adult heart transplant volume (ⱕ19 per year ⫽ lower-volume, ⱖ 20 ⫽ higher-volume). Temporal analyses of center volume and outcomes (1-month and 1-year observed-to-expected (O:E) patient death ratios) were performed using chi square testing. Results: 13,191 adult heart transplant procedures were analyzed. The percentage of heart transplants being performed in lower-volume centers increased significantly from 42.9% in Period 1 to 52.3% in Period 3 (p ⬍ 0.0001), while the percentage being performed in higher-volume centers decreased over the same time period (from 57.1% in Period 1 to 47.3% in Period 3, p ⬍ 0.0001). In Period 1, the 1-month O:E patient death ratio for lower-volume centers was significantly greater than the 1-month ratio for higher-volume centers (1.25 vs 0.81, p ⫽ 0.005). By Period 3, however, this discrepancy in outcomes was no longer statistically signficant (1.09 vs 0.90, p ⫽ 0.32). Similar findings were observed for 1-year O:E patient death ratios. Conclusions: Unlike lung transplantation, heart transplant procedures in the United States are increasingly being performed at lower-volume centers. These temporal changes in center volume are associated with a progressive weakening in the robustness of the relationship between the center volume of heart transplantation and recipient outcomes. Further investigation is warranted to determine why lung and heart transplantation have divergent regionalization patterns. 597 Use of Extracorporeal Membrane Oxygenation in Advanced Cardiogenic Shock Complicating an Acute Myocardial Infarction C. Bermudez, L. Wei, F. Avila, Y. Toyoda, M. Siegenthaler, C. Spadaccio, S. Mulukutla, J. Schindler, M. Refaat, R. Kormos University of Pittsburgh Medical Center, Pittsburgh, PA Purpose: Extracorporeal membrane oxygenation (ECMO) confers full hemodynamic support in patients with shock and severe hemodynamic involvement after an acute myocardial infarction (CS-AMI), with the advantage of implantation simplicity. We reviewed our institutional experience and outcomes in this population. Methods and Materials: 88 patients (pts) with CS-AMI evaluated for surgical consideration between June 2003 and Februray 2008 were analyzed retrospectively .22 pts required ECMO for stabilization and 66 pts underwent primary surgical revascularization (CABG). Results: 12 pts in the ECMO group had previous cardiac arrest ,21 were on high dose inotropes,19 had an intraaortic balloon (IABP) and 16 were on mechanical ventilation .Percutaneous approach was used in 20 pts with femoral access . The average time of support was 68.1 h (range 3-240). Eight pts (36%) were successfully weaned from ECMO.Of these 5 underwent CABG and 3 had PCI alone prior to ECMO removal. 11/22 patients were bridged to a ventricular assist device (VAD) with subsequent transplant (5 patients), recovery (1 patient) or died on VAD support (5 patients).13/22 pts (59%) survived to
Abstracts
S273
discharge.Of the CABG group 33 pts were on inotropes and 58 pts had IABP placed preoperatively.The majority of the pts, 42 (64%) underwent revascularization after 24 hours of diagnosis (1-7 days) and 13 pts within 24 hours. The hospital mortality on the entire CABG group was 28.8 % vs 41 % in the ECMO series (p⫽ 0.3). Kaplan Meier Survival curve is presented. Conclusions: Use of ECMO in selected patients with severely decompensated CS-AMI allow patient recovery from initial insult and facilitates an individual treatement strategy with improved short and mid term survival.
598 Physiological Changes Following Placement of Continuous Flow and Pulsatile Flow Left Ventricular Assist Devices B.A. Boilson1, J.A. Schirger1, B. Sareyyupoglu2, I. Penev2, C.G.A. McGregor2, L.C. Durham2, R.C. Daly2, B.S. Edwards1, S.J. Park2 1 Mayo Clinic, Rochester, MN; 2Mayo Clinic, Rochester, MN Purpose: Left ventricular assist devices (LVADs) are being used increasingly as a bridge to transplantation and also as a viable permanent option for patients unsuitable for transplantation. The bulk of data available on long term outcome with LVADs is based on the pulsatile flow (PU) device, but devices that deliver continuous blood flow (CF) are expected to be more durable. The aim of this study was to investigate physiologic effects of PU versus CFdesigns on physiologic changes post LVAD implantation. Methods and Materials: All patients who underwent LVAD implantation at out institution between May 2003 and July 2008 were evaluated. Baseline functional, echocardiographic, laboratory and cardiac catheterization data were recorded and compared with data at followup. Results: A total of 57 patients were studied. 42 patients underwent implantation of a CF device and 15 received a PU device. Comparison between device types revealed no significant differences in changes in hemodynamic or echocardiographic parameter changes following implantation of CF or PU devices. Conclusions: Both PU and CF devices are effective in offloading the left ventricle with reduction in LVIDD, PA pressures and MR severity. This is accompanied by an expected reduction in serum BNP. Numbers of pulsatile devices implanted were small which may account for lack of significance of some changes in this group compared to the CF group, and therefore extrapolations regarding relative efficacy are limited, but there is a suggestion that CF devices may be more efficacious in LV offloading. Finally, SVR increased following LVAD implantation, unlike