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Evolution of Mitral Regurgitation in Pulsatile Flow LVAD Patients Less Than 10kg
S282
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
Purpose: Prior studies have shown that, while renal function often improves after LVAD implantation, many patients do not recover renal function. Factors contributing to persistent renal dysfunction after LVAD placement have not been rigorously studied in children. The aim of this study is to identify hemodynamic/cardiac parameters that predict improved renal function following pediatric LVAD placement. Methods: A single-center retrospective cohort study was conducted in patients < 21 years with heart failure (HF) who underwent pulsatile or continuous flow LVAD placement between 5/2005 and 12/2015. Patients with right ventricular assist devices or single ventricle anatomy were excluded. The primary outcome was an improvement in estimated glomerular filtration rate (eGFR). We assessed the impact of pre/post-operative central venous pressures (CVP), qualitative right ventricular function and LV ejection fraction (EF) per echocardiography, pre-VAD right atrial pressure, pulmonary capillary wedge pressure (PCWP), and cardiac index. Univariate linear random-intercept models were used to determine the association of these variables with change in eGFR 14 days, 1 month, and 3 months after LVAD implantation. Results: 54 patients underwent LVAD placement. HF was due to cardiomyopathy in 49 (91%) and failed palliation of congenital heart disease in 5 (9%). A one mmHg increase in CVP at LVAD placement was associated with an increase of 3.3, 1.9, and 6.1 mL/min/1.73m2 in eGFR at 14 days (p= 0.04), 1 month (p= 0.26) and 3 months (p= 0.03) post-VAD, respectively. Additionally, a 5-point decline in CVP at 48 hours post-op was associated with a 22 mL/min/1.73m2 increase in eGFR at 3 months (p= 0.03); this association was also seen at all other time points, but was not statistically significant. A one L/min/m2 increase in pre-VAD cardiac index was associated with a 38.4 (p= 0.01) and 20.4 (p= 0.09) mL/min/1.73m2 increase in eGFR at 14 days and 1 month post-VAD, respectively. We did not find an association between pre-VAD EF, mean RA pressure, or PCWP with post-VAD eGFR. Conclusion: Higher CVP and cardiac index at LVAD implantation as well as a decline in CVP after LVAD placement are associated with improved longterm renal function in pediatric HF patients. This suggests that improved left ventricular output that effectively unloads the right heart can lead to improvement in renal function. 7( 44) Prevalence and Characteristics of Anemia and Hemolysis in Percutaneous Ventricular Assist Devices in a Pediatric Center K. Puri ,1 A. Jeewa,1 S.C. Tume,2 I. Adachi,3 S.W. Denfield,1 A.G. Cabrera,1 J.F. Price,1 H.P. Tunuguntla,1 W.J. Dreyer,1 M.D. Shah.4 1Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX; 2Critical Care Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, TX; 3Congenital Heart Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX; 4HematologyOncology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX. Purpose: Percutaneous ventricular assist devices (pcVAD), like the Impella® (Abiomed. Danvers, MA), have been used for acute decompensated heart failure. Hemolysis is a known complication with pcVADs. The prevalence of anemia in this population is uncharacterized. We hypothesized that (i) a majority of patients on pcVAD support have anemia, and (ii) their anemia is associated with hemolysis. Methods: We retrospectively reviewed all patients who were supported by pcVAD at Texas Children’s Hospital for > 12 hours from 2014 to 2016. Anemia (per WHO criteria for age) and iron deficiency (per iron, ferritin, transferrin, transferrin saturation) were identified. Hemolysis was defined as plasma free hemoglobin > 50 mg/dL on two occasions. Results: Ten patients receiving 13 pcVADs met inclusion criteria: 1 Impella®2.5, 4 Impella®5, 7 Impella®CP, 1 Impella®RP. Median age at implant was 18 years (IQR 14 - 20.5 years) and median support duration was 7 days (IQR 3.5 - 12 days). Dual pcVAD/ECMO support was used in 5 of 13 cases. Heparin-containing purge fluid was used per protocol. Hemolysis was seen in 6 of 13 cases during pcVAD support. pcVAD malposition was noted in 5 of 13 cases. The association between hemolysis and device malposition was insignificant; however the sample size was limited {p= 0.053, OR 12.00 (95% CI 0.80 - 180.97)}. Anemia was present in 2 of 13 cases at implant, and in 9 of 13 cases at explant. No association was noted between hemolysis and anemia at explant. Acute kidney insufficiency (AKI) at implant was associated
with anemia at explant (p= 0.003, OR 10, 95% CI 1.56 - 64.20). Iron deficiency (per iron indices) was noted in 3 of 6 cases (3 patients). Median packed red blood cell (pRBC) transfusion volume was 2.23 mL/kg/day (IQR 0 - 8.14 mL/kg/day). No association was noted between pRBC transfusion volume and hemolysis nor between pRBC transfusion volume and anemia. Anemia at implant was not associated with the combined outcome of mortality or transplant. Conclusion: Hemolysis and anemia were common in pcVAD patients. There was no association between anemia and hemolysis during pcVAD support. The association of AKI at implant and anemia in pcVAD patients at explant may reflect unrecognized co-morbidities influencing the severity of heart failure. 7( 45) Evolution of Mitral Regurgitation in Pulsatile Flow LVAD Patients Less Than 10kg A. Di Molfetta , R. Iacobelli, R. Adorisio, S. Filippelli, G. Perri, G. Testa, P. Guccione, A. Amodeo. Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Rome, Italy. Purpose: Left ventricular assist device (LVAD) is a treatment option for bridging pediatric patients to heart transplant. LVAD allows left ventricular (LV) unloading with an improvement in mitral regurgitation (MR). However, a significant MR may persist in some patients with LVAD. Methods: Echocardiographic data of 15 pediatric patients less than 10Kg undergoing pulsatile flow LVAD (Berlin Heart EXCOR) implantation were retrospectively collected before implantation and at one, three and six months after LVAD to assess LV unloading and MR evolution. Results: The etiology of heart failure was idiopathic dilative cardiomyopathy (79%) and LV noncompaction (21%). Mean time of LVAD support was 163.0±75.9days. Eleven patients (73%) were successfully transplanted and four patients (27%) died for major neurological complication. The incidence of moderate to severe MR was in 8/15 (53%) patients before implantation. No significant MR was evident in the whole population of 15 patient at 1-month follow up, but recurred in 5/11 (45%) patients at three months follow-up and in 4/6 (66%) patients at six months follow-up, respectively. At the univariate analysis, age, mitral valve annulus, left atrial size and vena contracta were predictive for residual significant MR after LVAD implantation. Conclusion: MR can recur after LVAD placement in pediatric patients. A patient-tailored and frequent LVAD programming could be tested to prolong the benefits of LVAD on LV unloading and MR.
Numbers 746-877 are Junior Faculty Clinical Case Reports which are not published in the Journal. 8( 78) Association of Insurance Coverage on the Development of Coronary Allograft Vasculopathy After Pediatric Heart Transplant E. Pruitt ,1 S. Urschel,2 M.D. Everitt,3 J.K. Kirklin,1 D.C. Naftel.1 1University of Alabama at Birmingham, Birmingham, AL; 2University of Alberta, Edmonton, AB, Canada; 3Children’s Hospital Colorado Heart Institute, Aurora, CO. Purpose: Pediatric heart transplants are a costly procedure with expensive follow up care. Although it has been shown that the cost of immunosuppression is not related to adherence, no formal study has evaluated the association of insurance
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
Purpose: Prior studies have shown that, while renal function often improves after LVAD implantation, many patients do not recover renal function. Factors contributing to persistent renal dysfunction after LVAD placement have not been rigorously studied in children. The aim of this study is to identify hemodynamic/cardiac parameters that predict improved renal function following pediatric LVAD placement. Methods: A single-center retrospective cohort study was conducted in patients < 21 years with heart failure (HF) who underwent pulsatile or continuous flow LVAD placement between 5/2005 and 12/2015. Patients with right ventricular assist devices or single ventricle anatomy were excluded. The primary outcome was an improvement in estimated glomerular filtration rate (eGFR). We assessed the impact of pre/post-operative central venous pressures (CVP), qualitative right ventricular function and LV ejection fraction (EF) per echocardiography, pre-VAD right atrial pressure, pulmonary capillary wedge pressure (PCWP), and cardiac index. Univariate linear random-intercept models were used to determine the association of these variables with change in eGFR 14 days, 1 month, and 3 months after LVAD implantation. Results: 54 patients underwent LVAD placement. HF was due to cardiomyopathy in 49 (91%) and failed palliation of congenital heart disease in 5 (9%). A one mmHg increase in CVP at LVAD placement was associated with an increase of 3.3, 1.9, and 6.1 mL/min/1.73m2 in eGFR at 14 days (p= 0.04), 1 month (p= 0.26) and 3 months (p= 0.03) post-VAD, respectively. Additionally, a 5-point decline in CVP at 48 hours post-op was associated with a 22 mL/min/1.73m2 increase in eGFR at 3 months (p= 0.03); this association was also seen at all other time points, but was not statistically significant. A one L/min/m2 increase in pre-VAD cardiac index was associated with a 38.4 (p= 0.01) and 20.4 (p= 0.09) mL/min/1.73m2 increase in eGFR at 14 days and 1 month post-VAD, respectively. We did not find an association between pre-VAD EF, mean RA pressure, or PCWP with post-VAD eGFR. Conclusion: Higher CVP and cardiac index at LVAD implantation as well as a decline in CVP after LVAD placement are associated with improved longterm renal function in pediatric HF patients. This suggests that improved left ventricular output that effectively unloads the right heart can lead to improvement in renal function. 7( 44) Prevalence and Characteristics of Anemia and Hemolysis in Percutaneous Ventricular Assist Devices in a Pediatric Center K. Puri ,1 A. Jeewa,1 S.C. Tume,2 I. Adachi,3 S.W. Denfield,1 A.G. Cabrera,1 J.F. Price,1 H.P. Tunuguntla,1 W.J. Dreyer,1 M.D. Shah.4 1Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX; 2Critical Care Medicine, Baylor College of Medicine/Texas Children's Hospital, Houston, TX; 3Congenital Heart Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX; 4HematologyOncology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX. Purpose: Percutaneous ventricular assist devices (pcVAD), like the Impella® (Abiomed. Danvers, MA), have been used for acute decompensated heart failure. Hemolysis is a known complication with pcVADs. The prevalence of anemia in this population is uncharacterized. We hypothesized that (i) a majority of patients on pcVAD support have anemia, and (ii) their anemia is associated with hemolysis. Methods: We retrospectively reviewed all patients who were supported by pcVAD at Texas Children’s Hospital for > 12 hours from 2014 to 2016. Anemia (per WHO criteria for age) and iron deficiency (per iron, ferritin, transferrin, transferrin saturation) were identified. Hemolysis was defined as plasma free hemoglobin > 50 mg/dL on two occasions. Results: Ten patients receiving 13 pcVADs met inclusion criteria: 1 Impella®2.5, 4 Impella®5, 7 Impella®CP, 1 Impella®RP. Median age at implant was 18 years (IQR 14 - 20.5 years) and median support duration was 7 days (IQR 3.5 - 12 days). Dual pcVAD/ECMO support was used in 5 of 13 cases. Heparin-containing purge fluid was used per protocol. Hemolysis was seen in 6 of 13 cases during pcVAD support. pcVAD malposition was noted in 5 of 13 cases. The association between hemolysis and device malposition was insignificant; however the sample size was limited {p= 0.053, OR 12.00 (95% CI 0.80 - 180.97)}. Anemia was present in 2 of 13 cases at implant, and in 9 of 13 cases at explant. No association was noted between hemolysis and anemia at explant. Acute kidney insufficiency (AKI) at implant was associated
with anemia at explant (p= 0.003, OR 10, 95% CI 1.56 - 64.20). Iron deficiency (per iron indices) was noted in 3 of 6 cases (3 patients). Median packed red blood cell (pRBC) transfusion volume was 2.23 mL/kg/day (IQR 0 - 8.14 mL/kg/day). No association was noted between pRBC transfusion volume and hemolysis nor between pRBC transfusion volume and anemia. Anemia at implant was not associated with the combined outcome of mortality or transplant. Conclusion: Hemolysis and anemia were common in pcVAD patients. There was no association between anemia and hemolysis during pcVAD support. The association of AKI at implant and anemia in pcVAD patients at explant may reflect unrecognized co-morbidities influencing the severity of heart failure. 7( 45) Evolution of Mitral Regurgitation in Pulsatile Flow LVAD Patients Less Than 10kg A. Di Molfetta , R. Iacobelli, R. Adorisio, S. Filippelli, G. Perri, G. Testa, P. Guccione, A. Amodeo. Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Rome, Italy. Purpose: Left ventricular assist device (LVAD) is a treatment option for bridging pediatric patients to heart transplant. LVAD allows left ventricular (LV) unloading with an improvement in mitral regurgitation (MR). However, a significant MR may persist in some patients with LVAD. Methods: Echocardiographic data of 15 pediatric patients less than 10Kg undergoing pulsatile flow LVAD (Berlin Heart EXCOR) implantation were retrospectively collected before implantation and at one, three and six months after LVAD to assess LV unloading and MR evolution. Results: The etiology of heart failure was idiopathic dilative cardiomyopathy (79%) and LV noncompaction (21%). Mean time of LVAD support was 163.0±75.9days. Eleven patients (73%) were successfully transplanted and four patients (27%) died for major neurological complication. The incidence of moderate to severe MR was in 8/15 (53%) patients before implantation. No significant MR was evident in the whole population of 15 patient at 1-month follow up, but recurred in 5/11 (45%) patients at three months follow-up and in 4/6 (66%) patients at six months follow-up, respectively. At the univariate analysis, age, mitral valve annulus, left atrial size and vena contracta were predictive for residual significant MR after LVAD implantation. Conclusion: MR can recur after LVAD placement in pediatric patients. A patient-tailored and frequent LVAD programming could be tested to prolong the benefits of LVAD on LV unloading and MR.
Numbers 746-877 are Junior Faculty Clinical Case Reports which are not published in the Journal. 8( 78) Association of Insurance Coverage on the Development of Coronary Allograft Vasculopathy After Pediatric Heart Transplant E. Pruitt ,1 S. Urschel,2 M.D. Everitt,3 J.K. Kirklin,1 D.C. Naftel.1 1University of Alabama at Birmingham, Birmingham, AL; 2University of Alberta, Edmonton, AB, Canada; 3Children’s Hospital Colorado Heart Institute, Aurora, CO. Purpose: Pediatric heart transplants are a costly procedure with expensive follow up care. Although it has been shown that the cost of immunosuppression is not related to adherence, no formal study has evaluated the association of insurance