Factors Affecting Post-Transplant Mortality in Patients Supported with Ventricular Assist Devices as Bridge to Transplantation



The 11th Annual Scientific Meeting

HFSA

S115

subjects received pre-implant colonoscopies. Seven had pathologic findings (4 polyps, 2 diverticulosis, 1 colitis), 3 of whom went on to develop post-implant GI bleeding (p 5 1.000). Conclusions: Nonpulsatile LVADs were not associated with an increase in AVMs or GI bleeding. The limited number of pre-implant colonoscopies was not predictive of post-implant GI bleeding. Table 1. Baseline Characteristics Nonpulsatile (n 5 25) Implant age in years Male Caucasian Pre-implant screening colonoscopy Days on device Ischemic cardiomyopathy Aortic stenosis (AV # 1.5 cm2)

52 6 15 16 (64%) 16 (64%) 6 (24%) 112 6 119 9 (36%) 1 (4%)

Pulsatile (n 5 27)

p Value

54 6 16 19 (70%) 17 (63%) 4 (15%) 254 6 251 13 (48%) 1 (4%)

0.495 0.633 0.843 0.411 0.013 0.386 0.957

Table 2. Post-LVAD Incidence of GI Bleeding

GI bleeding from AVM All GI bleeding

Nonpulsatile

Pulsatile

p Value

1 (4%) 2 (8%)

2 (7%) 6 (22%)

0.607 0.162

140 Factors Affecting Post-Transplant Mortality in Patients Supported with Ventricular Assist Devices as Bridge to Transplantation Amber M. Shah1, Marc A. Simon1, Duc Nguyen1, Jay Bhama1, Christian Bermudez1, Yoshiya Toyoda1, Jeffrey Teuteberg1, Kenneth McCurry1, Michael Siegenthaler1, Robert Kormos1; 1University of Pittsburgh Medical Center, Pittsburgh, PA Ventricular assist devices (VAD) for patients with severe heart failure (HF) are effective bridges to transplantation. Risk factors prior to VAD implantation may continue to exert an effect on mortality after transplantation. We performed this study to identify factors prior to VAD implantation that affect post-transplant mortality. Methods: We reviewed pre-implant data for consecutive adult HF patients that received VAD implantation between the years 1996 to 2003, followed by heart transplant. Primary outcome was post-transplant mortality. Univariate Cox Proportional hazard analysis was performed to identify factors predicting post-transplant mortality. Variables found to significantly predict mortality by univariate analysis were then evaluated in a multivariate model. Results: Ninety-nine patients (mean age: 49.1 6 12.2 years, 23.2% females, 44.4% with ischemic cardiomyopathy [ICM]) received VAD support followed by heart transplant. Devices used were 29 Novacor LVAS, 16 Heartmate LVAS VE, 19 Thoratec LVAD, 34 Thoratec BiVAD, and 1 Thoratec IVAD LVAD. Mean duration of VAD support prior to transplant was 123.7 6 109.6 days (range: 2 to 577 days). Mean follow-up post-transplant was 1044.2 6 944.6 days (range: 0 to 3007 days). 34/99 patients died post-transplant. Factors predicting posttransplant mortality in univariate analysis included diabetes (hazard ratio: 2.1, p 5 0.05) and end-organ dysfunction (defined as mechanical ventilation, creatinine clearance ! 30 or requiring hemodialysis, or transaminases or total bilirubin O three times upper limit of normal) prior to VAD (hazard ratio: 2.1, p 5 0.04). Patient age, gender, duration of VAD implant, IABP support for O 3 days prior to VAD, ICM, prior sternotomy, NYHA Class 4 symptoms, body mass index, mechanical ventilation, vasodilator therapy, and antiarrhythmic medication did not predict death post-transplantation. Multivariate analysis revealed that end-organ dysfunction prior to VAD and diabetes were significantly independently associated with mortality posttransplant (p 5 0.02 and 0.03 respectively). Conclusions: Diabetes and end-organ dysfunction prior to VAD implantation predict increased post-transplant mortality in bridge to transplant patients, suggesting a persistent adverse physiologic impact. Diabetes and end-organ dysfunction should be considered carefully in candidates for mechanical bridge to transplant.

141 Gastrointestinal Bleeding from Arteriovenous Malformations in Recipients of Left Ventricular Assist Devices Michael A. Grasso1, Jonathan M. Fenkel1, Erik N. Sorensen1, Erika D. Feller1; 1 Department of Medicine, University of Maryland Medical Center, Baltimore, MD Background: Arteriovenous malformations (AVMs) are abnormal blood vessels in the gastrointestinal (GI) tract and are a common source of bleeding. They can develop through venous obstruction or hypoperfusion, and may be associated with aortic stenosis or renal insufficiency. It has been suggested that nonpulsatile left ventricular assist devices (LVADs) may contribute to AVMs due to the lower pulse pressure generated by these devices, similar to aortic stenosis. Methods: We performed a retrospective analysis of 52 consecutive LVAD recipients. Nonpulsatile devices included VentrAssist, HeartMate II, and Jarvik 2000. Pulsatile devices included Novacor and HeartMate XVE. The primary endpoint was GI bleeding that was clinically evident by hematemesis, melena, guaiac positive stool, or iron deficiency anemia, and confirmed by endoscopy. Results: Key findings are in Tables 1 and 2. Only age was found to be an independent predictor of GI bleeding (p 5 0.001). Ten

142 A Cardiac Support Device Produces Incremental Clinical Benefits in Heart Failure Patients Treated with Cardiac Resynchronization Therapy William T. Abraham1, Juan M. Aranda2, Barry K. Rayburn3, John P. Boehmer4, Steven Krueger5, John V. Conte6, Andrew L. Smith7; 1Ohio State University, Columbus, OH; 2University of Florida, Gainesville, FL; 3University of Alabama, Birmingham, AL; 4Penn State Milton S Hershey Medical Center, Hershey, PA; 5 LGH Bryan Hospital, Lincoln, NE; 6Johns Hopkins Medical Institute, Baltimore, MD; 7Emory University, Atlanta, GA CRT improves clinical status in patients with advanced HF. However, many patients remain persistently symptomatic despite CRT. Cardiac support devices are emerging as a promising investigational approach for the treatment of symptomatic HF. This sub-analysis of a US non-randomized safety and feasibility trial of the HeartNet? device (Paracor Medical Inc., Sunnyvale, CA) evaluates the incremental benefits of an elastic cardiac support in patients receiving chronic CRT. Of 39 patients enrolled in the study, 19 were receiving chronic ($ 3 months) CRT at the time of HeartNet implantation. At baseline, these 19 patients had average (range) LVEF of 20.3 (11-33.2), LVEDV of 380 ml (210-652), LVESV of 306 ml (141-559), 6-min walk test (6MWT) distance of 364 m (168-494), peak VO2 of 15.5 ml/kg/min (6.9-26.3), and quality of life (MLWHF) score of 57.5 (24-88). At 6 month follow up, there were statistically significant improvements in LV parameters and a trend toward an improvement in LVEF and functional status (table). Conclusion: The addition of an elastic cardiac support device to standard HF treatment including CRT appears to result in additional improvements in cardiac structure and function and may improve functional status, as well. This notion must be confirmed in a larger group of HF patients that have been previously treated with CRT and then enrolled in the ongoing controlled, randomized PEERLESS-HF study.

LVEF (%) N 5 13 LV Mass (gm) N 5 9 LVESV (ml) N 5 13 LVEDV (ml) N 5 13 6MWT (m) N 5 13 Peak VO2 (ml/kg/min)N 5 14 MLWHF N 5 12

DBL to 6 mos (mean 6 SD)

p-value

6 6 6 6 6 6 6

0.122 0.022 0.012 0.018 0.092 0.960 0.054

2.8 -37.8 -38.3 -37.7 56.6 0.0 -13.2

6.0 40.1 46.7 49.8 111.2 3.2 20.1

143 Borderzone Pacing To Prevent Adverse Remodeling after Myocardial Infarction Landi M. Parish1, Hirostugu Hamamoto1, Joseph H. Gorman1, Robert C. Gorman1; 1 Harrison Department of Surgical Research, University of Pennsylvania, Philadelphia, PA Introduction: Increased wall stress in normally perfused myocardium adjacent to an infarct contributes to adverse remodeling, eventually leading to heart failure. Several interventions have been proposed to reduce wall stress by influencing the curvature of the borderzone. We instead target the timing of regional contraction, and propose a novel approach to reducing stress by ventricular pacing of the borderzone early in systole. Methods: Sonomicrometry crystals were placed over the surface of the ventricle in six sheep. Pacing wires were placed in the atrium and ventricular borderzone. Baseline data were recorded and an anteroapical infarct was created. One week