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Association Between Age, Bridge to Transplant Continuous Flow LVAD Use, and Outcomes After Heart Transplantation
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The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015
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60 mL/min/1.73 m² regardless of history of chronic renal dysfunction. Post LVAD major adverse outcomes were tabulated. Kaplan-Meier (KM) survival analysis was performed. Results: Patients with admission GFR < 60 had a higher incidence of hospitalizations for TIA/stroke (26 (16%) vs 8 (7%) p= 0.016), and heart failure (43 (27%) vs 14 (13%), p < 0.001) after LVAD placement. Similarly, these patients were also more likely to die of stroke and heart failure post-LVAD compared to patients with GFR ≥ 60 (73 (46%) vs 30 (27%) p= 0.001, and 89 (56%) vs 34 (30%) p< 0.001 respectively). KM analysis revealed a statistically significant difference in survival between the two groups at 3 years (Log rank p = 0.021) (Figure 1). Conclusion: Pre-implant GFR is an important prognostic marker in patients implanted with LVADs. Patients with GFR < 60 pre-implantation are at higher risk of cardiovascular mortality from stroke and heart failure.
Association Between Age, Bridge to Transplant Continuous Flow LVAD Use, and Outcomes After Heart Transplantation A. Ciarka ,1 L. Edwards,2 J. Stehlik,3 L. Lund.4 1Department of Cardiovascular Diseases, Catholic University of Leuven, Leuven, Belgium; 2ISHLT Transplant Registry, Dallas, TX; 3University of Utah Health, Salt Lake City, UT; 4Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden. Purpose: In heart transplantation, average recipient age and use of bridge to transplant left ventricular assist device (LVAD) are both increasing. We tested the hypothesis that continuous flow (CF) LVAD use is associated with worse post-transplant outcomes with increasing age. Methods: In 15,160 adult heart transplants between 2005 (when CF LVAD use increased) and 2013, post-transplant survival was assessed by Kaplan-Meier analysis: 1) among all patients by separate age groups (18-39, 40-59, ≥ 60 years), 2) among CF LVAD patients by separate age groups, and 3) in each age group for patients with CF LVAD vs. inotropes alone vs. neither treatment. We performed multivariable Cox proportional hazards regression analysis, where the model also included interactions between age and CF LVAD use. The model was based on the entire cohort, but the results are presented using a reference population treated with neither CF LVAD nor inotropes within each age group. Results: Overall 1-year post-transplant survival was 89%, 91% and 88% for patients aged 18-39, 40-59 and ≥ 60, and 5 year survival was 73%, 79% and 76% (p< 0.001), respectively. In CF LVAD patients, 1-year survival was 93%, 90% and 87%; and 5-year survival was 75%, 77% and 72% (Figure 1A). Within each age group, patients with CF LVADs did not have different survival compared to those without CF LVAD or with inotropes (Figure 1B-D). In multivariable analysis, CF LVAD use compared to neither CF LVAD nor inotrope use was not associated with worse survival after HTX in any age group: with similar hazard in 40-59 (HR 1.08, p= 0.29) and ≥ 60 years old (HR 1.11, p= 0.18), and lower hazard in 18-39 years (HR 0.78, p= 0.045). Conclusion: Higher age was associated with worse crude post-transplant survival both overall and in patients with CF LVAD. However, CF LVAD use was not associated with worse crude or adjusted post-transplant outcomes in any age group.
2( 05) Albuminuria Is Common in Patients Undergoing Left Ventricular Assist Device and Predicts Subsequent Renal Recovery M.A. Brisco ,1 A. Hale,1 D.P. Heyward,1 M.L. Craig,1 J.M. Testani.2 1Medicine-Cardiology, Med Univ of South Carolina, Charleston, SC; 2Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT.
2( 04) Pre-Implant Glomerular Filtration Rate (GFR) as a Predictor of Adverse Outcomes Post Left Ventricular Assist Device Placement B. Mohamedali , G. Yost, G. Bhat. Center for Heart Transplant and Assist Devices, Advocate Christ Medical Center, Oak Lawn, IL. Purpose: Although chronic renal dysfunction is a known predictor of adverse outcomes in patients with advanced heart failure requiring continuous flow left ventricular assist devices (LVADs), the effect of pre-LVAD reduction in glomerular filtration rate (GFR) on post-LVAD outcomes is not completely understood. Methods: This retrospective study enrolled 232 patients with continuous flow LVADs implanted for both bridge to transplantation and destination therapy. Patients were stratified based on a pre-implant GFR cutoff of
Purpose: Albuminuria defines a different dimension of renal dysfunction (RD) and is associated with adverse events independently of glomerular filtration rate. Albuminuria is often incorrectly assumed to indicate irreversible structural kidney disease; however, functional albuminuria caused by neurohormonal activation and hemodynamic aberrations are well described. Given the neurohormonal and hemodynamic perturbations in advanced heart failure (HF) patients, we hypothesized that albuminuria would be common pre-LVAD and predict renal recovery post LVAD. Methods: Patients undergoing LVAD implantation with 24-hour urine collections for albuminuria were evaluated (n= 84). Glomerular filtration rate (eGFR) was estimated using the Chronic Kidney Disease Epidemiology Collaboration Equation. RD was defined as an eGFR< 60 ml/min/1.73m2. Improvement in renal function was defined as ≥ 20% increase in eGFR at 1-month post LVAD. Results: The mean age of the cohort was 54.5 ± 13.8 years, of whom 50.0% had HTN and 34.5% had diabetes prior to LVAD implant. The mean urinary albumin excretion was elevated at 316.2 ± 382.9mg, with microalbuminuria (> 30mg/24h) present in 92.9% of patients and macroalbuminuria (> 300mg/24h) present in 26.2%. Substantial pre-LVAD RD was present with a mean baseline eGFR of 54.9 ± 21.9 ml/min/1.73m2. There was no difference in urine albumin excretion between those with and without pre-LVAD RD (314.1 ± 361.3 vs. 321.1 ± 437.7, p= 0.94). Notably, in
The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015
2( 03)
60 mL/min/1.73 m² regardless of history of chronic renal dysfunction. Post LVAD major adverse outcomes were tabulated. Kaplan-Meier (KM) survival analysis was performed. Results: Patients with admission GFR < 60 had a higher incidence of hospitalizations for TIA/stroke (26 (16%) vs 8 (7%) p= 0.016), and heart failure (43 (27%) vs 14 (13%), p < 0.001) after LVAD placement. Similarly, these patients were also more likely to die of stroke and heart failure post-LVAD compared to patients with GFR ≥ 60 (73 (46%) vs 30 (27%) p= 0.001, and 89 (56%) vs 34 (30%) p< 0.001 respectively). KM analysis revealed a statistically significant difference in survival between the two groups at 3 years (Log rank p = 0.021) (Figure 1). Conclusion: Pre-implant GFR is an important prognostic marker in patients implanted with LVADs. Patients with GFR < 60 pre-implantation are at higher risk of cardiovascular mortality from stroke and heart failure.
Association Between Age, Bridge to Transplant Continuous Flow LVAD Use, and Outcomes After Heart Transplantation A. Ciarka ,1 L. Edwards,2 J. Stehlik,3 L. Lund.4 1Department of Cardiovascular Diseases, Catholic University of Leuven, Leuven, Belgium; 2ISHLT Transplant Registry, Dallas, TX; 3University of Utah Health, Salt Lake City, UT; 4Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden. Purpose: In heart transplantation, average recipient age and use of bridge to transplant left ventricular assist device (LVAD) are both increasing. We tested the hypothesis that continuous flow (CF) LVAD use is associated with worse post-transplant outcomes with increasing age. Methods: In 15,160 adult heart transplants between 2005 (when CF LVAD use increased) and 2013, post-transplant survival was assessed by Kaplan-Meier analysis: 1) among all patients by separate age groups (18-39, 40-59, ≥ 60 years), 2) among CF LVAD patients by separate age groups, and 3) in each age group for patients with CF LVAD vs. inotropes alone vs. neither treatment. We performed multivariable Cox proportional hazards regression analysis, where the model also included interactions between age and CF LVAD use. The model was based on the entire cohort, but the results are presented using a reference population treated with neither CF LVAD nor inotropes within each age group. Results: Overall 1-year post-transplant survival was 89%, 91% and 88% for patients aged 18-39, 40-59 and ≥ 60, and 5 year survival was 73%, 79% and 76% (p< 0.001), respectively. In CF LVAD patients, 1-year survival was 93%, 90% and 87%; and 5-year survival was 75%, 77% and 72% (Figure 1A). Within each age group, patients with CF LVADs did not have different survival compared to those without CF LVAD or with inotropes (Figure 1B-D). In multivariable analysis, CF LVAD use compared to neither CF LVAD nor inotrope use was not associated with worse survival after HTX in any age group: with similar hazard in 40-59 (HR 1.08, p= 0.29) and ≥ 60 years old (HR 1.11, p= 0.18), and lower hazard in 18-39 years (HR 0.78, p= 0.045). Conclusion: Higher age was associated with worse crude post-transplant survival both overall and in patients with CF LVAD. However, CF LVAD use was not associated with worse crude or adjusted post-transplant outcomes in any age group.
2( 05) Albuminuria Is Common in Patients Undergoing Left Ventricular Assist Device and Predicts Subsequent Renal Recovery M.A. Brisco ,1 A. Hale,1 D.P. Heyward,1 M.L. Craig,1 J.M. Testani.2 1Medicine-Cardiology, Med Univ of South Carolina, Charleston, SC; 2Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT.
2( 04) Pre-Implant Glomerular Filtration Rate (GFR) as a Predictor of Adverse Outcomes Post Left Ventricular Assist Device Placement B. Mohamedali , G. Yost, G. Bhat. Center for Heart Transplant and Assist Devices, Advocate Christ Medical Center, Oak Lawn, IL. Purpose: Although chronic renal dysfunction is a known predictor of adverse outcomes in patients with advanced heart failure requiring continuous flow left ventricular assist devices (LVADs), the effect of pre-LVAD reduction in glomerular filtration rate (GFR) on post-LVAD outcomes is not completely understood. Methods: This retrospective study enrolled 232 patients with continuous flow LVADs implanted for both bridge to transplantation and destination therapy. Patients were stratified based on a pre-implant GFR cutoff of
Purpose: Albuminuria defines a different dimension of renal dysfunction (RD) and is associated with adverse events independently of glomerular filtration rate. Albuminuria is often incorrectly assumed to indicate irreversible structural kidney disease; however, functional albuminuria caused by neurohormonal activation and hemodynamic aberrations are well described. Given the neurohormonal and hemodynamic perturbations in advanced heart failure (HF) patients, we hypothesized that albuminuria would be common pre-LVAD and predict renal recovery post LVAD. Methods: Patients undergoing LVAD implantation with 24-hour urine collections for albuminuria were evaluated (n= 84). Glomerular filtration rate (eGFR) was estimated using the Chronic Kidney Disease Epidemiology Collaboration Equation. RD was defined as an eGFR< 60 ml/min/1.73m2. Improvement in renal function was defined as ≥ 20% increase in eGFR at 1-month post LVAD. Results: The mean age of the cohort was 54.5 ± 13.8 years, of whom 50.0% had HTN and 34.5% had diabetes prior to LVAD implant. The mean urinary albumin excretion was elevated at 316.2 ± 382.9mg, with microalbuminuria (> 30mg/24h) present in 92.9% of patients and macroalbuminuria (> 300mg/24h) present in 26.2%. Substantial pre-LVAD RD was present with a mean baseline eGFR of 54.9 ± 21.9 ml/min/1.73m2. There was no difference in urine albumin excretion between those with and without pre-LVAD RD (314.1 ± 361.3 vs. 321.1 ± 437.7, p= 0.94). Notably, in