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Chronic renal failure in a 10-year National Cohort of Pediatric Heart Transplant recipients
S114
Abstracts
resolution of symptomatic EBV disease or PTLD. Outcomes were compared to control patients with low/absent viral loads. Results: Data were analyzed on 71 pediatric heart transplant recipients who had serial EBV-PCR studies since 1997; chronic high load (20 pts) low load (39), absent load (12). High load patients included 7 with prior early onset PTLD, 8 with symptomatic EBV infection and 5 with no prior clinical EBV disease. Of these, 8/20 (40%) developed the following B cell lesions at a mean of 6 years (range 2.4 –7.9) after transplant; Burkitt’s lymphoma (4 patients), recurrent or refractory polymorphic PTLD (3, including CNS relapse in one case), and a cutaneous marginal zone B cell lymphoma in 1. Among 51 controls with low or absent viral loads, only 2 (3.9%: P ⬍ 0.001 control vs. high load) developed late PTLD/ lymphoma (EBV-negative plasma cell PTLD and peripheral T cell lymphoma, 1 case each). Conclusions: Chronic high EBV-load carrier state in the asymptomatic heart transplant recipient is not benign and is a strong predictor of de novo or recurrent PTLD, with the majority being of monomorphic / lymphomatous histology.
220 CHRONIC RENAL FAILURE IN A 10-YEAR NATIONAL COHORT OF PEDIATRIC HEART TRANSPLANT RECIPIENTS C.K. Lee,1,2 L.L. Christensen,3 J.C. Magee,4 A.O. Ojo,4 A.B. Leichtman,4 N.D. Bridges,2 1Pediatric Cardiology, Children’s National Medical Center, Washington, DC; 2National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD; 3 SRTR/URREA, Ann Arbor, MI; 4SRTR/University of Michigan, Ann Arbor, MI Renal dysfunction can occur after pediatric heart transplantation (PHTx). We examined the incidence of chronic renal failure (CRF) after PHTx, associated pre-transplant patient characteristics, and the impact of CRF on survival. Methods: Data sources included the Scientific Registry of Transplant Recipients, the Centers for Medicare and Medicaid Services, and the Social Security Death Master File. Included were all PHTx recipients (age ⬍18y) in the U.S. from 1990 to 1999 who survived ⬎1 year. CRF was defined as creatinine (Cr) ⬎2.5 mg/dl, chronic dialysis (CD) and/or kidney transplant (KTx). The relationships between pre-transplant characteristics and time to CRF were analyzed using Cox proportional hazards models. The effect of CRF on subsequent survival was analyzed using a time-dependent Cox model. Results: Of 2032 PHTx recipients, 138 (6.8%) developed CRF. Of these, 61 (44%) went on to CD and/or KTx. The actuarial risk for CRF was 3.2% at 5 years and 9.1% at 10 years. In multivariable analysis, significant risk factors for CRF were African-American race (hazard ratio (HR) 2.1, p⫽0.0004), inotropic support (HR 1.6, p⫽0.02), and diagnosis of hypertrophic cardiomyopathy versus congenital heart disease (HR 2.7, p ⫽ 0.035). Younger age (⬍2y) was associated with a reduced risk of CRF (HR 0.44, p⫽0.002) compared to ages 2–10y. Gender, pre-transplant Cr⬎2.5 mg/dl, ventilator, and support device were not significantly related to CRF. Adjusted risk of death in those who developed CRF was 7.6 times higher than in those without CRF (p⬍0.0001). Conclusion: CRF developed in nearly 7% of PHTx recipients and was associated with significantly increased mortality. These findings will allow improved patient counseling and they highlight the importance of minimizing exposure to nephrotoxic agents in those at highest risk for CRF.
The Journal of Heart and Lung Transplantation February 2005
221 CORONARY STENOSIS DETECTION BY 16-SLICE COMPUTED TOMOGRAPHY IN HEART TRANSPLANT PATIENTS: COMPARISON WITH CONVENTIONAL CORONARY ANGIOGRAPHY AND IMPACT ON CLINICAL MANAGEMENT G. Romeo, L. Houyel, J.F. Paul, P. Brenot, J.Y. Riou, C.Y. Angel, Radiology, Marie-Lannelongue Hospital, Le Plessis-Robinson, France Cardiac allograft vasculopathy (CAV) is the main limiting factor for long-term success of heart transplantation (HT). Routine annual conventional coronary angiography (CCA) is the gold standard for diagnosis and follow-up of CAV. With the aim of finding a noninvasive alternative to CCA, we studied the efficacy of multi-slice (16-slice) computed tomography coronary angiography (MSCT) in the detection of significant focal stenosis (⬎50%) in a population of HT pts. Since 04/2003, 53 consecutive HT pts (mean post-HT time 7.6 ⫾ 3.8 yrs, range 1–14.5 ; mean age at HT 40.6 ⫾ 19 yrs, range 1.6 – 66) underwent MSCT within 24 hours before or after their annual routine CCA. Only angiographic segments ⬎1.5 mm were considered for analysis. Three pts were excluded because impossible breath hold (2) or atrial fibrillation (1). Of 450 angiographic coronary segments, 432 (96%) were evaluable by MSCT. Analysis of the segments showed sensitivity 80%, specificity 99%, positive predictive value (PPV) 80%, negative predictive value (NPV) 99%, accuracy 99%. Among 9 coronary stents in 7 patients, only 3 could be correctly analyzed by MSCT including 1 intra-stent restenosis (ISR), but 2 significant ISR were missed. Of 50 pts, 44 (88%) could be completely analyzed. In the 20 pts with strictly normal MSCT, no stenosis was found at CCA. Analysis of the coronary segments showed sensitivity 83%, specificity 95%, PPV 71%, NPV 95%, accuracy 93%. Our study confirms the potential role of MSCT for non-invasive follow-up of HT patients and suggests the following guidelines, already applied in our institution : 1) annual MSCT can replace CCA in de novo HT pts ; 2) pts with a strictly normal MSCT at follow-up may avoid subsequent CCA ; 3) significant modifications on annual MSCT may lead to CCA ; 4) at the present time, MSCT is not reliable for detection of ISR and pts with stents require CCA. This limitation may be overcome with the expected improvements in MSCT technology. 222 MECHANISM AND PREVENTION OF TRICUSPID VALVE REGURGITATION AFTER ORTHOTOPIC HEART TRANSPLANTATION C. Knosalla,1 M. Dandel,1 S. Buz,1 F. Knollmann,2 Y.G. Weng,1 M. Pasic,1 O. Grauhan,1 H.B. Lehmkuhl,1 R. Hetzer,1 1Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany; 2Department of Radiology, ChariteUniversity Medicine Berlin, Berlin, Germany Objectives: Tricuspid regurgitation (TR) is a common complication after heart transplantation (HTx). We investigated the mechanism of TR development in patients undergoing HTx using the standard biatrial anastomosis technique. Methods: In 150 patients with biatrial anastomosis(1–12 years after HTx), detailed echocardiographic assessments, including morphological and functional tricuspid valve (TV) evaluations and measurement of right atrial (RA) geometry, tricuspid annulus (TA) systolic excursion and tissue Doppler wall motion velocity at different levels of the TA and atrial anastomosis, were performed in addition to invasive hemodynamic evaluations and cardiac computer tomography scans. Biopsy-related TR was excluded from the study. Results: Patients with TR grade I had higher RA anterior wall donor/recipient(D/R) length ratios than those without TR(1.03 0.13 vs. 0.80 0.16; p⫽0.0011); in those without TR the RA anterior wall
Abstracts
resolution of symptomatic EBV disease or PTLD. Outcomes were compared to control patients with low/absent viral loads. Results: Data were analyzed on 71 pediatric heart transplant recipients who had serial EBV-PCR studies since 1997; chronic high load (20 pts) low load (39), absent load (12). High load patients included 7 with prior early onset PTLD, 8 with symptomatic EBV infection and 5 with no prior clinical EBV disease. Of these, 8/20 (40%) developed the following B cell lesions at a mean of 6 years (range 2.4 –7.9) after transplant; Burkitt’s lymphoma (4 patients), recurrent or refractory polymorphic PTLD (3, including CNS relapse in one case), and a cutaneous marginal zone B cell lymphoma in 1. Among 51 controls with low or absent viral loads, only 2 (3.9%: P ⬍ 0.001 control vs. high load) developed late PTLD/ lymphoma (EBV-negative plasma cell PTLD and peripheral T cell lymphoma, 1 case each). Conclusions: Chronic high EBV-load carrier state in the asymptomatic heart transplant recipient is not benign and is a strong predictor of de novo or recurrent PTLD, with the majority being of monomorphic / lymphomatous histology.
220 CHRONIC RENAL FAILURE IN A 10-YEAR NATIONAL COHORT OF PEDIATRIC HEART TRANSPLANT RECIPIENTS C.K. Lee,1,2 L.L. Christensen,3 J.C. Magee,4 A.O. Ojo,4 A.B. Leichtman,4 N.D. Bridges,2 1Pediatric Cardiology, Children’s National Medical Center, Washington, DC; 2National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD; 3 SRTR/URREA, Ann Arbor, MI; 4SRTR/University of Michigan, Ann Arbor, MI Renal dysfunction can occur after pediatric heart transplantation (PHTx). We examined the incidence of chronic renal failure (CRF) after PHTx, associated pre-transplant patient characteristics, and the impact of CRF on survival. Methods: Data sources included the Scientific Registry of Transplant Recipients, the Centers for Medicare and Medicaid Services, and the Social Security Death Master File. Included were all PHTx recipients (age ⬍18y) in the U.S. from 1990 to 1999 who survived ⬎1 year. CRF was defined as creatinine (Cr) ⬎2.5 mg/dl, chronic dialysis (CD) and/or kidney transplant (KTx). The relationships between pre-transplant characteristics and time to CRF were analyzed using Cox proportional hazards models. The effect of CRF on subsequent survival was analyzed using a time-dependent Cox model. Results: Of 2032 PHTx recipients, 138 (6.8%) developed CRF. Of these, 61 (44%) went on to CD and/or KTx. The actuarial risk for CRF was 3.2% at 5 years and 9.1% at 10 years. In multivariable analysis, significant risk factors for CRF were African-American race (hazard ratio (HR) 2.1, p⫽0.0004), inotropic support (HR 1.6, p⫽0.02), and diagnosis of hypertrophic cardiomyopathy versus congenital heart disease (HR 2.7, p ⫽ 0.035). Younger age (⬍2y) was associated with a reduced risk of CRF (HR 0.44, p⫽0.002) compared to ages 2–10y. Gender, pre-transplant Cr⬎2.5 mg/dl, ventilator, and support device were not significantly related to CRF. Adjusted risk of death in those who developed CRF was 7.6 times higher than in those without CRF (p⬍0.0001). Conclusion: CRF developed in nearly 7% of PHTx recipients and was associated with significantly increased mortality. These findings will allow improved patient counseling and they highlight the importance of minimizing exposure to nephrotoxic agents in those at highest risk for CRF.
The Journal of Heart and Lung Transplantation February 2005
221 CORONARY STENOSIS DETECTION BY 16-SLICE COMPUTED TOMOGRAPHY IN HEART TRANSPLANT PATIENTS: COMPARISON WITH CONVENTIONAL CORONARY ANGIOGRAPHY AND IMPACT ON CLINICAL MANAGEMENT G. Romeo, L. Houyel, J.F. Paul, P. Brenot, J.Y. Riou, C.Y. Angel, Radiology, Marie-Lannelongue Hospital, Le Plessis-Robinson, France Cardiac allograft vasculopathy (CAV) is the main limiting factor for long-term success of heart transplantation (HT). Routine annual conventional coronary angiography (CCA) is the gold standard for diagnosis and follow-up of CAV. With the aim of finding a noninvasive alternative to CCA, we studied the efficacy of multi-slice (16-slice) computed tomography coronary angiography (MSCT) in the detection of significant focal stenosis (⬎50%) in a population of HT pts. Since 04/2003, 53 consecutive HT pts (mean post-HT time 7.6 ⫾ 3.8 yrs, range 1–14.5 ; mean age at HT 40.6 ⫾ 19 yrs, range 1.6 – 66) underwent MSCT within 24 hours before or after their annual routine CCA. Only angiographic segments ⬎1.5 mm were considered for analysis. Three pts were excluded because impossible breath hold (2) or atrial fibrillation (1). Of 450 angiographic coronary segments, 432 (96%) were evaluable by MSCT. Analysis of the segments showed sensitivity 80%, specificity 99%, positive predictive value (PPV) 80%, negative predictive value (NPV) 99%, accuracy 99%. Among 9 coronary stents in 7 patients, only 3 could be correctly analyzed by MSCT including 1 intra-stent restenosis (ISR), but 2 significant ISR were missed. Of 50 pts, 44 (88%) could be completely analyzed. In the 20 pts with strictly normal MSCT, no stenosis was found at CCA. Analysis of the coronary segments showed sensitivity 83%, specificity 95%, PPV 71%, NPV 95%, accuracy 93%. Our study confirms the potential role of MSCT for non-invasive follow-up of HT patients and suggests the following guidelines, already applied in our institution : 1) annual MSCT can replace CCA in de novo HT pts ; 2) pts with a strictly normal MSCT at follow-up may avoid subsequent CCA ; 3) significant modifications on annual MSCT may lead to CCA ; 4) at the present time, MSCT is not reliable for detection of ISR and pts with stents require CCA. This limitation may be overcome with the expected improvements in MSCT technology. 222 MECHANISM AND PREVENTION OF TRICUSPID VALVE REGURGITATION AFTER ORTHOTOPIC HEART TRANSPLANTATION C. Knosalla,1 M. Dandel,1 S. Buz,1 F. Knollmann,2 Y.G. Weng,1 M. Pasic,1 O. Grauhan,1 H.B. Lehmkuhl,1 R. Hetzer,1 1Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany; 2Department of Radiology, ChariteUniversity Medicine Berlin, Berlin, Germany Objectives: Tricuspid regurgitation (TR) is a common complication after heart transplantation (HTx). We investigated the mechanism of TR development in patients undergoing HTx using the standard biatrial anastomosis technique. Methods: In 150 patients with biatrial anastomosis(1–12 years after HTx), detailed echocardiographic assessments, including morphological and functional tricuspid valve (TV) evaluations and measurement of right atrial (RA) geometry, tricuspid annulus (TA) systolic excursion and tissue Doppler wall motion velocity at different levels of the TA and atrial anastomosis, were performed in addition to invasive hemodynamic evaluations and cardiac computer tomography scans. Biopsy-related TR was excluded from the study. Results: Patients with TR grade I had higher RA anterior wall donor/recipient(D/R) length ratios than those without TR(1.03 0.13 vs. 0.80 0.16; p⫽0.0011); in those without TR the RA anterior wall