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Do Donor Characteristics Matter? Prediction of Graft Utilization and Recipient Outcomes after Heart Transplantation
Abstracts
S93
Correlation Between Echo Parameter and Treadmill Time
Echo Parameter
RVTEI RV S’ LV S’ Mitral E/e’ Mean PA pressure IVC diameter LVIDD % increase CO with stress Increase RV S’ with stress Increase LV S’ with stress n
Spearman Correlation Coefficient (r)
p-value
Adjusted R-square
p-value
0.0483 0.09172 0.30464 0.54706 0.45522
0.8643 0.7355 0.2513 0.0283 0.0663
0.0000 0.0001 0.1133 0.3074 0.3539
0.9982 0.9814 0.2519 0.0429 0.0267
0.62508 0.01474 0.60989
0.0168 0.9552 0.0269
0.3913 0.0303 0.4251
0.0612 0.5633 0.0121
0.23321
0.3847
0.1456
0.2145
0.51025
0.1088
0.0462
0.5305
Adjusted for age, sex, BSA, and Borg score
echocardiographic markers of resting and dynamic ventricular systolic function as well as resting filling pressures would be predictors of exercise tolerance in these patients. Methods and Materials: 17 outpatients (mean age 60.6, mean 527 days post-implant, 41% destination therapy) with LVAD (16 HeartMate II, 1 Heartware) underwent symptom-limited exercise treadmill echocardiography with modified Bruce protocol and Borg scale reporting. A complete echocardiogram was performed at rest and an RV-focused echocardiogram was performed at peak stress. Linear correlation and multiple linear regression with adjustment for age, sex, BSA, and Borg score were used to relate echocardiographic variables to treadmill duration. Results: Along with ability to augment cardiac output, baseline low LV filling pressure (Mitral E/e’) and pulmonary pressure (MPAP) predicted increased exercise capacity, while resting and dynamic markers of RV and LV systolic function did not. Conclusions: Low resting LV (E/e’) and low mean PA pressure along with ability to augment cardiac output correlated significantly with exercise capacity while resting and dynamic measures of right and left ventricular systolic function did not. Therapies that lower filling pressures and optimization of LVAD unloading may provide symptomatic benefit in this population.
one (86.1%) exhibited CI following LVAD placement. The severity of CI was correlated with the peak VO2 (r¼0.38, p¼0.02). There were no differences between those with and without CI with respect to age, gender, cardiomyopathy type, diabetes mellitus prevalence, disease duration, beta-blocker use, or time on mechanical support. Seven patients had a second CPET with activated RRP 36þ33 days after the first test. In 4 patients RRP resulted in a higher heart rate and in these patients peak VO2 improved by an average increase of 1.4þ 0.8ml/min/kg. Conclusions: CI is common among patients with advanced HF following LVAD placement. The severity of CI correlated with exercise performance in LVAD patients. RRP represents a possible intervention to improve exercise performance.
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233
Chronotropic Incompetence May Impact Exercise Capacity in Patients Supported by Left Ventricular Assist Device A.R. Garan,1 N. Nahumi,1 J. Han,1 P. Colombo,1 M. Yuzefpolskaya,1 R. Te-Frey,2 H. Takayama,2 Y. Naka,2 N. Uriel,1 U.P. Jorde.1 1 Cardiology, Columbia University Medical Center, New York, NY; 2 Cardiothoracic Surgery, Columbia University Medical Center, New York, NY.
Do Donor Characteristics Matter? Prediction of Graft Utilization and Recipient Outcomes after Heart Transplantation K.K. Khush,1 R. Menza,2 J. Nguyen,3 J.G. Zaroff,4 B.A. Goldstein.1 1 Stanford University, Palo Alto, CA; 2Victoria University, Wellington, New Zealand; 3California Transplant Donor Network, Oakland, CA; 4 Kaiser Northern California Division of Research, Oakland, CA.
Purpose: Chronotropic incompetence (CI) is common in advanced heart failure (HF) patients. However, its prevalence and significance in patients with a left ventricular assist device (LVAD) is unknown. This study sought to determine whether CI is predictive of exercise performance in this patient population and whether it may be overcome by rate-responsive pacing (RRP). Methods and Materials: A prospective study of LVAD patients undergoing a cardio-pulmonary exercise test (CPET) was performed. CI was defined as the inability to achieve 80% of the maximal ageadjusted predicted heart rate. Clinical and CPET data were collected and analyzed according to the presence of CI. Results: Thirty-six patients were enrolled. Mean age was 58.3þ13.1 years, 77.8% were men, and 61.1% were bridge-to-transplant. Thirty-
Purpose: Despite a national organ shortage and a growing population of patients with end-stage heart disease, the acceptance rate of donor grafts for transplantation is low. We sought to identify donor predictors of allograft non-utilization and to determine whether these predictors are associated with adverse recipient outcomes. We then developed statistical models incorporating donor and recipient-specific variables to predict survival post-transplant. Methods and Materials: We studied a cohort of 1872 potential organ donors managed by the California Transplant Donor Network from 2001-8. 43% of available grafts were accepted for heart transplant. We used a Random Forest (RF) model, an extension of decision tree analysis, to predict allograft utilization. We then created RF models to predict recipient survival using donor characteristics alone, and donor plus recipient characteristics at the time of transplant.
S94
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
Results: The RF model developed to predict cardiac allograft utilization performed well, with a C-statistic of 0.85. The most important predictors were donor age, cause of death, left ventricular ejection fraction, and history of hypertension. However, among hearts that were transplanted, only donor diabetes was associated with increased recipient mortality. Models developed to predict recipient survival were less accurate, with C-statistics of 0.58 and 0.52 for 30-day and 1-year survival, respectively, using donor characteristics alone, and C-statistics of 0.62 and 0.61 for 30-day and 1-year survival using both donor and recipient characteristics at transplant. Conclusions: While there are many donor predictors of allograft discard in the current era, these factors appear to have little relationship with recipient outcomes when the hearts are transplanted. It is difficult to predict recipient post-transplant survival, even knowing donor and recipient characteristics at the time of transplant. Our results support calls for liberalization of current cardiac allograft acceptance practices. 234 Does Cardiopulmonary Arrest and Resuscitation of Heart Donors Portend Inferior Outcomes in Heart Transplantation Recipients? M.A. Quader, L.G. Wolfe, V. Kasirajan. Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA. Purpose: Myocardial ischemia sustained during cardiopulmonary arrest and resuscitation of a heart donor (CPRþ) is thought to be associated with suboptimal graft function and poor outcomes in recipients. We examined graft and recipient survival in patients receiving heart transplantation from CPRþ donors and compared them to recipients whose heart donors did not sustain cardiac arrest (CPR-). Methods and Materials: Retrospective analysis of UNOS adult heart transplantation data from May 1994 through July 2012 was performed. Discrete variables were compared using the Chi-Square test. Continuous variables were compared using t test. Patient and graft survivals were calculated using actuarial method and compared using Wilcoxon test. Results: Of the 29,242 adult heart transplantations performed in North America during study period, 1,396 (4.7%) received hearts from CPRþ donors. More number of young 25.5⫾15yrs vs. 28.5⫾14yrs Po0.0001 and female donors 31% vs. 27% P 0.001 were represented in CPRþ
group. Mean duration of CPR was 20min. Recipients 1A status at transplantation was 54% for CPRþ and 47% for CPR-, Po0.0001 groups. More patients were hospitalized and were in the intensive care unit at transplantation in CPRþ group, 56% vs. 51%, P 0.0008. Recipients survival at 30 days, 1yr and 5yr in CPRþ and CPR- groups was 95%, 88%, 73% and 94.7%, 87.7%, 74.4% respectively. Graft survival mirrored recipient survival in both groups. Conclusions: A large multicenter adult heart transplant data from across North America did not show inferior outcomes in recipients of heart transplantation from selected CPRþ donors. Recipient and graft survival were similar over five years of follow-up.
235 Donor Pulmonary Status Impacts Survival in Cardiac Transplant Recipients J.L. Madden,1 B.C. Baird,1 J. Stehlik,2 S.G. Drakos,2 S.H. McKellar,1 J.N. Nativi,2 C.H. Selzman.1 1Cardiothoracic Surgery, University of Utah Hospitals & Clinics, Salt Lake City, UT; 2Cardiology, University of Utah Hospitals & Clinics, Salt Lake City, UT. Purpose: Cardiac preconditioning observed during ischemic and physiologic stress can enhance outcomes following subsequent myocardial injury. Transplantation provides obligate ischemia on a relatively healthy donor heart. Hearts are procured from donors from which the lungs may or may not be suitable for transplantation. We hypothesized that hearts exposed to lungs deemed to be unacceptable for lung transplant would be preconditioned and thereby have improved post-transplant survival compared to hearts retrieved from donors with both heart and lungs procured. Methods and Materials: We examined adult cardiac transplant recipients within the United Network for Organ Sharing database from 1998-2012. Two groups were identified: lung donor ¼ LD, non lung donor ¼ NLD. Kaplan Meier unadjusted survival analysis and Cox proportional-hazards regression was performed. Results: Of 51,546 patients who underwent cardiac transplantation, 29,601 (57.4%) were from a LD. At 30 days post-transplant, survival was not different between groups. However, at 1, 5 and 10 years, patients who received a heart from a LD had worse survival than from a NLD (unadjusted HR ¼ 1.59, po0.0001). LD recipient age was higher (49.7 vs 44.7) and donor systolic PA pressure was lower (26.4 vs 30.9). More NLD had a history of smoking (10.6% vs. 9.3%). At 10 years, the adjusted survival rate greatly favored hearts transplanted from NLDs (HR ¼ 1.43, po0.0001). Conclusions: Cardiac transplant recipients from donors with unsuitable lungs had similar survival, suggesting that acutely preconditioned hearts neither enhance nor worsen perioperative survival. The potential effects of preconditioning and other factors accounting for the marked difference in long-term survival remain to be determined.
S93
Correlation Between Echo Parameter and Treadmill Time
Echo Parameter
RVTEI RV S’ LV S’ Mitral E/e’ Mean PA pressure IVC diameter LVIDD % increase CO with stress Increase RV S’ with stress Increase LV S’ with stress n
Spearman Correlation Coefficient (r)
p-value
Adjusted R-square
p-value
0.0483 0.09172 0.30464 0.54706 0.45522
0.8643 0.7355 0.2513 0.0283 0.0663
0.0000 0.0001 0.1133 0.3074 0.3539
0.9982 0.9814 0.2519 0.0429 0.0267
0.62508 0.01474 0.60989
0.0168 0.9552 0.0269
0.3913 0.0303 0.4251
0.0612 0.5633 0.0121
0.23321
0.3847
0.1456
0.2145
0.51025
0.1088
0.0462
0.5305
Adjusted for age, sex, BSA, and Borg score
echocardiographic markers of resting and dynamic ventricular systolic function as well as resting filling pressures would be predictors of exercise tolerance in these patients. Methods and Materials: 17 outpatients (mean age 60.6, mean 527 days post-implant, 41% destination therapy) with LVAD (16 HeartMate II, 1 Heartware) underwent symptom-limited exercise treadmill echocardiography with modified Bruce protocol and Borg scale reporting. A complete echocardiogram was performed at rest and an RV-focused echocardiogram was performed at peak stress. Linear correlation and multiple linear regression with adjustment for age, sex, BSA, and Borg score were used to relate echocardiographic variables to treadmill duration. Results: Along with ability to augment cardiac output, baseline low LV filling pressure (Mitral E/e’) and pulmonary pressure (MPAP) predicted increased exercise capacity, while resting and dynamic markers of RV and LV systolic function did not. Conclusions: Low resting LV (E/e’) and low mean PA pressure along with ability to augment cardiac output correlated significantly with exercise capacity while resting and dynamic measures of right and left ventricular systolic function did not. Therapies that lower filling pressures and optimization of LVAD unloading may provide symptomatic benefit in this population.
one (86.1%) exhibited CI following LVAD placement. The severity of CI was correlated with the peak VO2 (r¼0.38, p¼0.02). There were no differences between those with and without CI with respect to age, gender, cardiomyopathy type, diabetes mellitus prevalence, disease duration, beta-blocker use, or time on mechanical support. Seven patients had a second CPET with activated RRP 36þ33 days after the first test. In 4 patients RRP resulted in a higher heart rate and in these patients peak VO2 improved by an average increase of 1.4þ 0.8ml/min/kg. Conclusions: CI is common among patients with advanced HF following LVAD placement. The severity of CI correlated with exercise performance in LVAD patients. RRP represents a possible intervention to improve exercise performance.
232
233
Chronotropic Incompetence May Impact Exercise Capacity in Patients Supported by Left Ventricular Assist Device A.R. Garan,1 N. Nahumi,1 J. Han,1 P. Colombo,1 M. Yuzefpolskaya,1 R. Te-Frey,2 H. Takayama,2 Y. Naka,2 N. Uriel,1 U.P. Jorde.1 1 Cardiology, Columbia University Medical Center, New York, NY; 2 Cardiothoracic Surgery, Columbia University Medical Center, New York, NY.
Do Donor Characteristics Matter? Prediction of Graft Utilization and Recipient Outcomes after Heart Transplantation K.K. Khush,1 R. Menza,2 J. Nguyen,3 J.G. Zaroff,4 B.A. Goldstein.1 1 Stanford University, Palo Alto, CA; 2Victoria University, Wellington, New Zealand; 3California Transplant Donor Network, Oakland, CA; 4 Kaiser Northern California Division of Research, Oakland, CA.
Purpose: Chronotropic incompetence (CI) is common in advanced heart failure (HF) patients. However, its prevalence and significance in patients with a left ventricular assist device (LVAD) is unknown. This study sought to determine whether CI is predictive of exercise performance in this patient population and whether it may be overcome by rate-responsive pacing (RRP). Methods and Materials: A prospective study of LVAD patients undergoing a cardio-pulmonary exercise test (CPET) was performed. CI was defined as the inability to achieve 80% of the maximal ageadjusted predicted heart rate. Clinical and CPET data were collected and analyzed according to the presence of CI. Results: Thirty-six patients were enrolled. Mean age was 58.3þ13.1 years, 77.8% were men, and 61.1% were bridge-to-transplant. Thirty-
Purpose: Despite a national organ shortage and a growing population of patients with end-stage heart disease, the acceptance rate of donor grafts for transplantation is low. We sought to identify donor predictors of allograft non-utilization and to determine whether these predictors are associated with adverse recipient outcomes. We then developed statistical models incorporating donor and recipient-specific variables to predict survival post-transplant. Methods and Materials: We studied a cohort of 1872 potential organ donors managed by the California Transplant Donor Network from 2001-8. 43% of available grafts were accepted for heart transplant. We used a Random Forest (RF) model, an extension of decision tree analysis, to predict allograft utilization. We then created RF models to predict recipient survival using donor characteristics alone, and donor plus recipient characteristics at the time of transplant.
S94
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
Results: The RF model developed to predict cardiac allograft utilization performed well, with a C-statistic of 0.85. The most important predictors were donor age, cause of death, left ventricular ejection fraction, and history of hypertension. However, among hearts that were transplanted, only donor diabetes was associated with increased recipient mortality. Models developed to predict recipient survival were less accurate, with C-statistics of 0.58 and 0.52 for 30-day and 1-year survival, respectively, using donor characteristics alone, and C-statistics of 0.62 and 0.61 for 30-day and 1-year survival using both donor and recipient characteristics at transplant. Conclusions: While there are many donor predictors of allograft discard in the current era, these factors appear to have little relationship with recipient outcomes when the hearts are transplanted. It is difficult to predict recipient post-transplant survival, even knowing donor and recipient characteristics at the time of transplant. Our results support calls for liberalization of current cardiac allograft acceptance practices. 234 Does Cardiopulmonary Arrest and Resuscitation of Heart Donors Portend Inferior Outcomes in Heart Transplantation Recipients? M.A. Quader, L.G. Wolfe, V. Kasirajan. Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, VA. Purpose: Myocardial ischemia sustained during cardiopulmonary arrest and resuscitation of a heart donor (CPRþ) is thought to be associated with suboptimal graft function and poor outcomes in recipients. We examined graft and recipient survival in patients receiving heart transplantation from CPRþ donors and compared them to recipients whose heart donors did not sustain cardiac arrest (CPR-). Methods and Materials: Retrospective analysis of UNOS adult heart transplantation data from May 1994 through July 2012 was performed. Discrete variables were compared using the Chi-Square test. Continuous variables were compared using t test. Patient and graft survivals were calculated using actuarial method and compared using Wilcoxon test. Results: Of the 29,242 adult heart transplantations performed in North America during study period, 1,396 (4.7%) received hearts from CPRþ donors. More number of young 25.5⫾15yrs vs. 28.5⫾14yrs Po0.0001 and female donors 31% vs. 27% P 0.001 were represented in CPRþ
group. Mean duration of CPR was 20min. Recipients 1A status at transplantation was 54% for CPRþ and 47% for CPR-, Po0.0001 groups. More patients were hospitalized and were in the intensive care unit at transplantation in CPRþ group, 56% vs. 51%, P 0.0008. Recipients survival at 30 days, 1yr and 5yr in CPRþ and CPR- groups was 95%, 88%, 73% and 94.7%, 87.7%, 74.4% respectively. Graft survival mirrored recipient survival in both groups. Conclusions: A large multicenter adult heart transplant data from across North America did not show inferior outcomes in recipients of heart transplantation from selected CPRþ donors. Recipient and graft survival were similar over five years of follow-up.
235 Donor Pulmonary Status Impacts Survival in Cardiac Transplant Recipients J.L. Madden,1 B.C. Baird,1 J. Stehlik,2 S.G. Drakos,2 S.H. McKellar,1 J.N. Nativi,2 C.H. Selzman.1 1Cardiothoracic Surgery, University of Utah Hospitals & Clinics, Salt Lake City, UT; 2Cardiology, University of Utah Hospitals & Clinics, Salt Lake City, UT. Purpose: Cardiac preconditioning observed during ischemic and physiologic stress can enhance outcomes following subsequent myocardial injury. Transplantation provides obligate ischemia on a relatively healthy donor heart. Hearts are procured from donors from which the lungs may or may not be suitable for transplantation. We hypothesized that hearts exposed to lungs deemed to be unacceptable for lung transplant would be preconditioned and thereby have improved post-transplant survival compared to hearts retrieved from donors with both heart and lungs procured. Methods and Materials: We examined adult cardiac transplant recipients within the United Network for Organ Sharing database from 1998-2012. Two groups were identified: lung donor ¼ LD, non lung donor ¼ NLD. Kaplan Meier unadjusted survival analysis and Cox proportional-hazards regression was performed. Results: Of 51,546 patients who underwent cardiac transplantation, 29,601 (57.4%) were from a LD. At 30 days post-transplant, survival was not different between groups. However, at 1, 5 and 10 years, patients who received a heart from a LD had worse survival than from a NLD (unadjusted HR ¼ 1.59, po0.0001). LD recipient age was higher (49.7 vs 44.7) and donor systolic PA pressure was lower (26.4 vs 30.9). More NLD had a history of smoking (10.6% vs. 9.3%). At 10 years, the adjusted survival rate greatly favored hearts transplanted from NLDs (HR ¼ 1.43, po0.0001). Conclusions: Cardiac transplant recipients from donors with unsuitable lungs had similar survival, suggesting that acutely preconditioned hearts neither enhance nor worsen perioperative survival. The potential effects of preconditioning and other factors accounting for the marked difference in long-term survival remain to be determined.