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Does Time on Ventricular Assist Device Compromise Post-Transplant Outcome?
S178
The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015
Conclusion: Novel scoring system using 4 CPX parameters significantly stratified both re-admission and cardiac death in patients with HF receiving optimal medical therapy.
4( 71) Cardiac Retransplantation: Third Time’s the Charm? E.C. DePasquale , L. Reardon, A. Nsair, M. Deng, A. Ardehali. UCLA, Los Angeles, CA. Purpose: Redo heart transplantation (HT) poses an ethical issue given the scarcity of donors. We sought to investigate long-term outcomes in those receiving second (HT-2) and third transplant (HT-3). Methods: 19706 first HT, 742 HT-2 & 46 HT-3 pts were identified from the UNOS Registry (2003-2012). Exclusions included: rHT> 1 & follow-up (FU) loss. Survival was censored at 12y & multivariate Cox proportional hazard regression models were adjusted for age, sex, DM, race, ischemic time, dialysis, etiology, life support, wait time & HLA mismatch. Results: Mean age was 45y ± 20. Amongst HT-2 & HT-3 pts, transplant vasculopathy was the most prevalent indication (n= 378 (51%) vs 21 (46%), respectively) whereas dilated (9052, 46%) and ischemic cardiomyopathy (7046, 36%) was most prevalent for first-time HT. FU began at time of first HT (mean 52 ± 36 months). 5472 pts died (26% first-HT, 34% HT-2 & 43% HT-3), p < 0.001). Crude survival is shown (Figure). Survival was significantly better for first-HT compared to HT-2 & HT-3. No significant difference in survival was observed comparing HT-2 & HT-3. Unadjusted HR for all-cause mortality (compared to first-HT) was 1.33 (CI 1.19-1.52) [HT-2] & 1.68 (CI 1.09-2.61) [HT-3). Multivariate Cox proportional hazards regression analysis yielded a HR of 1.38 (CI 1.20-1.59) [HT-2] & 1.78 (CI 1.07-2.96) [HT-3]. Redo pts were more likely to be younger (p < 0.001), female (p < 0.001), less likely to have diabetes (p= 0.007), less likely to have ventricular assist device support (p < 0.001), with shorter wait time (p= 0.030) (Figure). Conclusion: In selected patients, redo heart transplantation can be performed with acceptable short and long-term outcomes. No difference in survival was observed between second or third-time HT.
4( 72) Mid-Term Outcome of Acute Fulminant Myocarditis Presenting With Cardiogenic Shock: A Single Centre Experience E. Ammirati , M. Lilliu, M. Cipriani, A. Garascia, M. Brambatti, F.M. Turazza, S. Nonnini, R. Paino, C.F. Russo, F. Oliva, M. Frigerio. Niguarda Ca’ Granda Hospital, Milan, Italy. Purpose: fulminant myocarditis (FM) is a high-risk condition. The impact of temporary mechanical circulatory supports (MCS) on the outcome of these patients has not been specifically evaluated. We describe survival and changes in left ventricular ejection fraction (LVEF) in a single center retrospective series of FM. Methods: FM was defined by 1) cardiogenic shock requiring inotropes and/ or MCS; 2) onset of symptoms within 1 month from admission; 3) confirmative histology at endomyocardial biopsy (EMB), autopsy, or transplantation (HTx). On these basis, 32 consecutive patients (pts; 50% males, mean age 28±16y, including 7 children< 16 y) presenting with FM from 2002 to 2014 were analyzed. Median follow up was 968 days (I and III quartile [Q1-Q3]: 484-1668 days). Results: 23 patients (72%) were supported with a MCS: arterial-venous extracorporeal membrane oxygenator (av-ECMO) and intra-aortic balloon pump (IABP), n= 1 0; central ECMO, 2 pediatric patients; IABP only, n= 8; LVAD, n= 2; Impella recovery system, 1 pt EMB was performed in 80% of adult patients. In-hospital survival was 88% (n= 28, 100% in pediatric group). No deaths were reported during follow up. HTx-free survival was 78%, with 2HTx in the initial hospitalization and one performed 1 year after LVAD implantation. At histology, the most frequent diagnosis was lymphocytic myocarditis (55%). Giant cell myocarditis (GCM) was diagnosed in 4 cases, with 2 patients requiring urgent HTx, one dying, and one surviving after days on ECMO+IABP and aggressive immunosuppression. Median baseline LVEF was 20% [Q1-Q3: 15-35%]). Patients who survived without HTx had a median LVEF increase of 34% (Q1-Q3: 23-42%). At the end of follow up 71% of them had a LVEF > 55%. Conclusion: Prompt use of MCS and immunosuppression guided by clinical judgment allowed an 88% survival with normal or near-to-normal LVEF in a high risk population of patients with FM, stressing the importance of early referral to tertiary care specialized centers. 4( 73) Does Time on Ventricular Assist Device Compromise Post-Transplant Outcome? K. Ghafourian , J. Moriguchi, M. Kittleson, L. Czer, E. Passano, F. Liou, N. Huie, D.H. Chang, A. Trento, F. Arabia, J. Kobashigawa. Cedars-Sinai Heart Institute, Los Angeles, CA. Purpose: The use of continuous left ventricular assist devices (LVAD) has been increasing over the past several years. More patients are being listed as status 1a and status 1b while on LVAD support. This is resulting in increased waiting time on the heart transplant waiting list. Post LVAD complications also increase but it is not known whether LVAD and posttransplant complications increase with an increasing rate with longer LVAD implantation. Methods: Between 2008 and 2013, we evaluated 55 LVAD patients. LVAD patients were divided based on their time on device: 12 months (n= 16). Freedom from LVAD complications, defined as infection, bleeding, thrombus, stroke, device malfunction, and renal dysfunction. Post-transplant outcomes included: 1-year survival, freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/ pacemaker insertion, stroke), treated infections, treated rejections, and hospital readmissions. Results: Freedom from complications following LVAD implantation for these time periods was not significantly different among the 3 groups. There was also no difference in the average number of LVAD complications per patient across the study groups. The percent of patients listed as status 1a as well as 1b at transplant were similar across the 3 groups. Post-transplant survival, freedom from NF-MACE, treated infections, treated rejections, and hospital readmissions were similar among all 3 groups. (See table)
Abstracts S179 Conclusion: Although the waitlist time for continuous flow LVAD patients is increasing, there does not appear to be an increase in complications. Post-transplant outcomes were independent of time on waitlist with VAD. Therefore, there does not appear to be compromise of outcome for longer waitlist time.
1-Year Actuarial Survival 1-Year Actuarial Freedom from NF-MACE 1-Year Actuarial Freedom from Treated Infection 1-Year Actuarial Freedom from Readmission Average Number of Readmissions 1-Year Actuarial Freedom from Any-Treated Rejection 1-Year Actuarial Freedom from Treated Cellular Rejection 1-Year Actuarial Freedom from Treated Antibody Mediated Rejection Average Post-Transplant Length of Stay (Days) Freedom from MCS Complications Average Number of MCS Complications per Patient *P= NS for all comparisons
< 6 Months (n= 29)
6-12 Months (n= 10)
> 12 Months (n= 16)
86.9% 96.3%
90.0% 100.0%
100.0% 79.5%
81.5%
100.0%
87.5%
51.4%
41.7%
59.1%
0.5 ± 0.7
0.7 ± 0.7
1.6 ± 2.5
90.5%
80.0%
72.7%
100.0%
100.0%
93.8%
100.0%
100.0%
100.0%
13.7 ± 8.3
11.4 ± 3.8
12.3 ± 5.4
60.0% (15/25)
60.% (6/10)
64.3% (9/14)
1.9 ± 1.2
2.2 ± 1.3
1.6 ± 0.9
4( 74) Outcomes in Adult Heart Transplant Candidates and Recipients Bridged With Acute Circulatory Support Devices S.C. Silvestry ,1 L.B. Edwards,2 L. Robbins,2 S.A. Hall,3 J.G. Rogers,4 D.M. Meyer.5 1Washington Univ Sch of Med, St. Louis, MO; 2UNOS, Richmond, VA; 3Transplant Cardiology and Mechanical Support/Heart Failure, Baylor University Medical Center, Dallas, TX; 4Internal Medicine, Duke University School of Medicine, Durham, NC; 5Surgery, University of Texas Southwestern Medical Schoo, Dallas, TX. Purpose: Acute circulatory support (ACS) devices are increasingly used in patients waiting for heart transplant yet sparse data exist on their use alone and with implantable LVADs. To assess bridging with ACS, data from patients supported with ACS at listing and at transplant were evaluated for waiting list death/transplant rates and post-transplant survival for recipients with ACS at transplant. Methods: OPTN data was queried for adult heart candidates ever waiting (excluding those listed for any other organs) between 1/1/2011-12/31/2013 (10,809 candidates) and adult primary heart transplant recipients during the same interval, excluding multi-organ transplants (4,610 transplants). Cohorts were grouped by type of ACS. Results: In patients listed with ACS, both waiting list death rates and transplant rates were significantly higher compared to patients listed with non ACS LVAD and with no MCS. Post-transplant 1 year mortality was highest for patients transplanted while on ECMO or ACS. IABP supported patients achieved 1 year mortality comparable to non-MCS transplanted patients. Conclusion: The ACS cohort had different waiting list, death/withdrawal,and transplant rates and post-transplant outcomes: ACS LVAD pts had higher waiting list mortality and transplant rates than IABP and IABP + non-ACS LVAD supported patients. Patients transplanted on ACS LVADs had lower post-transplant survival than IABP supported patients. Caution should be used extrapolating these results due to the small ACS subgroup sample sizes and possible migration of waiting list patients from ACS to other groups at transplant.
Device at listing
Device at transplant
1-year # of TXs mortality
# of TXs
1-year mortality
1-year # of TXs mortality
10.1 7.1
214 20
7.5 20.0
70
7.2
29.4 13.6
32
37.5
7.8
1760
9.0
1054
7.7
8.6 15.8
2305 178
7.6 13.6
2273 102
7.5 15.8
1. IABP 151 2. ACS 14 (Impella, Tandem Heart) 3. ECMO 17 4. IABP + 22 Non-ACS LVAD 5. Non-ACS 1080 LVAD 6. No MCSD 3124 7. Non-ACS 115 biventricular support
Same device at listing and at transplant
The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015
Conclusion: Novel scoring system using 4 CPX parameters significantly stratified both re-admission and cardiac death in patients with HF receiving optimal medical therapy.
4( 71) Cardiac Retransplantation: Third Time’s the Charm? E.C. DePasquale , L. Reardon, A. Nsair, M. Deng, A. Ardehali. UCLA, Los Angeles, CA. Purpose: Redo heart transplantation (HT) poses an ethical issue given the scarcity of donors. We sought to investigate long-term outcomes in those receiving second (HT-2) and third transplant (HT-3). Methods: 19706 first HT, 742 HT-2 & 46 HT-3 pts were identified from the UNOS Registry (2003-2012). Exclusions included: rHT> 1 & follow-up (FU) loss. Survival was censored at 12y & multivariate Cox proportional hazard regression models were adjusted for age, sex, DM, race, ischemic time, dialysis, etiology, life support, wait time & HLA mismatch. Results: Mean age was 45y ± 20. Amongst HT-2 & HT-3 pts, transplant vasculopathy was the most prevalent indication (n= 378 (51%) vs 21 (46%), respectively) whereas dilated (9052, 46%) and ischemic cardiomyopathy (7046, 36%) was most prevalent for first-time HT. FU began at time of first HT (mean 52 ± 36 months). 5472 pts died (26% first-HT, 34% HT-2 & 43% HT-3), p < 0.001). Crude survival is shown (Figure). Survival was significantly better for first-HT compared to HT-2 & HT-3. No significant difference in survival was observed comparing HT-2 & HT-3. Unadjusted HR for all-cause mortality (compared to first-HT) was 1.33 (CI 1.19-1.52) [HT-2] & 1.68 (CI 1.09-2.61) [HT-3). Multivariate Cox proportional hazards regression analysis yielded a HR of 1.38 (CI 1.20-1.59) [HT-2] & 1.78 (CI 1.07-2.96) [HT-3]. Redo pts were more likely to be younger (p < 0.001), female (p < 0.001), less likely to have diabetes (p= 0.007), less likely to have ventricular assist device support (p < 0.001), with shorter wait time (p= 0.030) (Figure). Conclusion: In selected patients, redo heart transplantation can be performed with acceptable short and long-term outcomes. No difference in survival was observed between second or third-time HT.
4( 72) Mid-Term Outcome of Acute Fulminant Myocarditis Presenting With Cardiogenic Shock: A Single Centre Experience E. Ammirati , M. Lilliu, M. Cipriani, A. Garascia, M. Brambatti, F.M. Turazza, S. Nonnini, R. Paino, C.F. Russo, F. Oliva, M. Frigerio. Niguarda Ca’ Granda Hospital, Milan, Italy. Purpose: fulminant myocarditis (FM) is a high-risk condition. The impact of temporary mechanical circulatory supports (MCS) on the outcome of these patients has not been specifically evaluated. We describe survival and changes in left ventricular ejection fraction (LVEF) in a single center retrospective series of FM. Methods: FM was defined by 1) cardiogenic shock requiring inotropes and/ or MCS; 2) onset of symptoms within 1 month from admission; 3) confirmative histology at endomyocardial biopsy (EMB), autopsy, or transplantation (HTx). On these basis, 32 consecutive patients (pts; 50% males, mean age 28±16y, including 7 children< 16 y) presenting with FM from 2002 to 2014 were analyzed. Median follow up was 968 days (I and III quartile [Q1-Q3]: 484-1668 days). Results: 23 patients (72%) were supported with a MCS: arterial-venous extracorporeal membrane oxygenator (av-ECMO) and intra-aortic balloon pump (IABP), n= 1 0; central ECMO, 2 pediatric patients; IABP only, n= 8; LVAD, n= 2; Impella recovery system, 1 pt EMB was performed in 80% of adult patients. In-hospital survival was 88% (n= 28, 100% in pediatric group). No deaths were reported during follow up. HTx-free survival was 78%, with 2HTx in the initial hospitalization and one performed 1 year after LVAD implantation. At histology, the most frequent diagnosis was lymphocytic myocarditis (55%). Giant cell myocarditis (GCM) was diagnosed in 4 cases, with 2 patients requiring urgent HTx, one dying, and one surviving after days on ECMO+IABP and aggressive immunosuppression. Median baseline LVEF was 20% [Q1-Q3: 15-35%]). Patients who survived without HTx had a median LVEF increase of 34% (Q1-Q3: 23-42%). At the end of follow up 71% of them had a LVEF > 55%. Conclusion: Prompt use of MCS and immunosuppression guided by clinical judgment allowed an 88% survival with normal or near-to-normal LVEF in a high risk population of patients with FM, stressing the importance of early referral to tertiary care specialized centers. 4( 73) Does Time on Ventricular Assist Device Compromise Post-Transplant Outcome? K. Ghafourian , J. Moriguchi, M. Kittleson, L. Czer, E. Passano, F. Liou, N. Huie, D.H. Chang, A. Trento, F. Arabia, J. Kobashigawa. Cedars-Sinai Heart Institute, Los Angeles, CA. Purpose: The use of continuous left ventricular assist devices (LVAD) has been increasing over the past several years. More patients are being listed as status 1a and status 1b while on LVAD support. This is resulting in increased waiting time on the heart transplant waiting list. Post LVAD complications also increase but it is not known whether LVAD and posttransplant complications increase with an increasing rate with longer LVAD implantation. Methods: Between 2008 and 2013, we evaluated 55 LVAD patients. LVAD patients were divided based on their time on device: 12 months (n= 16). Freedom from LVAD complications, defined as infection, bleeding, thrombus, stroke, device malfunction, and renal dysfunction. Post-transplant outcomes included: 1-year survival, freedom from non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/ pacemaker insertion, stroke), treated infections, treated rejections, and hospital readmissions. Results: Freedom from complications following LVAD implantation for these time periods was not significantly different among the 3 groups. There was also no difference in the average number of LVAD complications per patient across the study groups. The percent of patients listed as status 1a as well as 1b at transplant were similar across the 3 groups. Post-transplant survival, freedom from NF-MACE, treated infections, treated rejections, and hospital readmissions were similar among all 3 groups. (See table)
Abstracts S179 Conclusion: Although the waitlist time for continuous flow LVAD patients is increasing, there does not appear to be an increase in complications. Post-transplant outcomes were independent of time on waitlist with VAD. Therefore, there does not appear to be compromise of outcome for longer waitlist time.
1-Year Actuarial Survival 1-Year Actuarial Freedom from NF-MACE 1-Year Actuarial Freedom from Treated Infection 1-Year Actuarial Freedom from Readmission Average Number of Readmissions 1-Year Actuarial Freedom from Any-Treated Rejection 1-Year Actuarial Freedom from Treated Cellular Rejection 1-Year Actuarial Freedom from Treated Antibody Mediated Rejection Average Post-Transplant Length of Stay (Days) Freedom from MCS Complications Average Number of MCS Complications per Patient *P= NS for all comparisons
< 6 Months (n= 29)
6-12 Months (n= 10)
> 12 Months (n= 16)
86.9% 96.3%
90.0% 100.0%
100.0% 79.5%
81.5%
100.0%
87.5%
51.4%
41.7%
59.1%
0.5 ± 0.7
0.7 ± 0.7
1.6 ± 2.5
90.5%
80.0%
72.7%
100.0%
100.0%
93.8%
100.0%
100.0%
100.0%
13.7 ± 8.3
11.4 ± 3.8
12.3 ± 5.4
60.0% (15/25)
60.% (6/10)
64.3% (9/14)
1.9 ± 1.2
2.2 ± 1.3
1.6 ± 0.9
4( 74) Outcomes in Adult Heart Transplant Candidates and Recipients Bridged With Acute Circulatory Support Devices S.C. Silvestry ,1 L.B. Edwards,2 L. Robbins,2 S.A. Hall,3 J.G. Rogers,4 D.M. Meyer.5 1Washington Univ Sch of Med, St. Louis, MO; 2UNOS, Richmond, VA; 3Transplant Cardiology and Mechanical Support/Heart Failure, Baylor University Medical Center, Dallas, TX; 4Internal Medicine, Duke University School of Medicine, Durham, NC; 5Surgery, University of Texas Southwestern Medical Schoo, Dallas, TX. Purpose: Acute circulatory support (ACS) devices are increasingly used in patients waiting for heart transplant yet sparse data exist on their use alone and with implantable LVADs. To assess bridging with ACS, data from patients supported with ACS at listing and at transplant were evaluated for waiting list death/transplant rates and post-transplant survival for recipients with ACS at transplant. Methods: OPTN data was queried for adult heart candidates ever waiting (excluding those listed for any other organs) between 1/1/2011-12/31/2013 (10,809 candidates) and adult primary heart transplant recipients during the same interval, excluding multi-organ transplants (4,610 transplants). Cohorts were grouped by type of ACS. Results: In patients listed with ACS, both waiting list death rates and transplant rates were significantly higher compared to patients listed with non ACS LVAD and with no MCS. Post-transplant 1 year mortality was highest for patients transplanted while on ECMO or ACS. IABP supported patients achieved 1 year mortality comparable to non-MCS transplanted patients. Conclusion: The ACS cohort had different waiting list, death/withdrawal,and transplant rates and post-transplant outcomes: ACS LVAD pts had higher waiting list mortality and transplant rates than IABP and IABP + non-ACS LVAD supported patients. Patients transplanted on ACS LVADs had lower post-transplant survival than IABP supported patients. Caution should be used extrapolating these results due to the small ACS subgroup sample sizes and possible migration of waiting list patients from ACS to other groups at transplant.
Device at listing
Device at transplant
1-year # of TXs mortality
# of TXs
1-year mortality
1-year # of TXs mortality
10.1 7.1
214 20
7.5 20.0
70
7.2
29.4 13.6
32
37.5
7.8
1760
9.0
1054
7.7
8.6 15.8
2305 178
7.6 13.6
2273 102
7.5 15.8
1. IABP 151 2. ACS 14 (Impella, Tandem Heart) 3. ECMO 17 4. IABP + 22 Non-ACS LVAD 5. Non-ACS 1080 LVAD 6. No MCSD 3124 7. Non-ACS 115 biventricular support
Same device at listing and at transplant