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Functional mitral regugitation in advanced heart failure
S44 Journal of Cardiac Failure Vol. 9 No. 5 Suppl. 2003 155
156
Bridge to Heart Transplantation: A Comparison of Ventricular Assist Device and Inotropic Support Susan Moffatt,1 Michael Chan,2 Philippe Demers,1 Philip Oyer,1 Bruce Reitz,1 Robert Robbins1—1Cardiothoracic Surgery, Stanford University, Stanford, CA; 2 Cardiovascular Medicine, Stanford University, Stanford, CA
Functional Mitral Regugitation in Advanced Heart Failure Jeetendra B. Patel,1 Daniel D. Borgeson,1 Charanjit S. Rihal,1 Margaret M. Redfield1—1Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, MN
Background: Bridge to heart transplantation using ventricular assist devices (VAD) or inotropic support has traditionally been thought to be associated with poor outcomes. Patient selection and device sophistication have however improved and donor shortages often necessitate prolonged circulatory support. We therefore reviewed the outcomes of Status 2 patients and patients bridged to heart transplantation with inotropic or VAD support. Methods: Since 1984, 588 heart transplants have been performed involving: Group I: VAD-bridge to transplantation (n ⫽ 47); Group II: inotropic-bridge to transplantation (n ⫽ 148) and Group III: Status 2 patients (n ⫽ 393). The demographics of these patient groups were reviewed and survival rates calculated. Results: Group I had an average wait to transplantation of 115 days, compared to 79 days for Group II and 176 days for Group III (p ⫽ ns). The median time to first rejection episode was 37 days, 30 days and 28 days for Groups I, II and III respectively (p ⫽ ns) with all groups having the same number of rejection episodes. ICU stay and overall hospitalization was longer for Group I (9 and 31 days, respectively) compared to that of Group II and III (2 and 23 days, respectively) (p ⫽ ns). The 30 day mortality rates were 2%, 5% and 5% for Groups I, II and III, respectively with that of Group I being sigficantly less than that of both Group II and Group III (p ⬍ 0.05). The actuarial survival rates at 90 days, 1, 5 and 10 years were: Group I: 98%, 92%, 80% and 71%, Group II: 88%, 82%, 72% and 52% and Group III: 91%, 83%, 65% and 45%, respectively. These survival outomes were significantly better for the VAD-bridged group (Group I) compared to both inotropic-bridged (Group II) and Status 2 (Group III) patients (p ⬍ 0.05). Conclusions: Overall survival for patients who were bridged to heart transplantation with VAD support was significantly better compared to both Status 2 and inotrope supported patients. This improved survival was realized without a signicant increase in waiting time, ICU stay, hospital stay or rejection episodes. Therefore, at our institution, the use of a VAD as a bridge to heart transplantation has resulted in better than previously perceived outcomes.
Background: Patients with dilated cardiomyopathy develop mitral regurgitation (MR) in the absence of organic mitral valve disease (functional MR, FMR). FMR may contribute to worsening symptoms and survival in heart failure (HF) and surgical or devicebased percutaneous annuloplasty is purposed as a therapeutic strategy for patients with advanced HF. Objectives: Our objective was to define the prevalence, clinical correlates and prognostic implications of FMR and the current utilization of mitral annuloplasty in patients with advanced HF evaluated in a HF Clinic. Methods: We reviewed clinical, echocardiographic and survival data from all patients with advanced systolic HF (NYHA class III or IV; EF ⬍0.35) due to ischemic or idiopathic cardiomyopathy evaluated at Mayo HF Clinic between January 1996 and September 2001. Patients with organic mitral valve disease were excluded. Results: 558 patients met criteria and had satisfactory echocardiograms. See table. The severity of FMR was confirmed by quantitative analysis (PISA) in 88% of patients with Severe, 79% of patients with Moderate-Severe, 66% of patients with Moderate, 45% of patients with Mild-Moderate and 15% of patients with Mild FMR with calculation of effective regurgitant orifice (ERO) and regurgitant volume. Severe or Moderate–Severe tricuspid regurgitation was present in 50% of patients with Severe FMR, 33% of patients with Moderate–Severe FMR and 15% of patients with Moderate FMR. Patients with hemodynamically significant (ⱖModerate) FMR had higher mortality in univariate analysis (p ⬍ 0.03) but not when controlling for age, sex, etiology, NYHA class and EF (p ⫽ 0.67). Patients with hemodynamically significant tricuspid regurgitation had higher mortality in univariate (p ⫽ 0.002) and tended to have higher mortality in multivariate analysis (p ⫽ 0.06). Only three patients were referred for mitral valve repair subsequent to HF Clinic evaluation. Conclusion: Hemodynamically significant FMR is common among patients with advanced HF, yet surgical treatment of FMR is rarely performed. Device based therapy for FMR may expand the use of FMR reduction as a therapeutic strategy for advanced HF although concomitant tricuspid regurgitation may limit its utility. While FMR has been shown to be strongly correlated with mortality in unselected populations with systolic dysfunction or HF, correlation with mortality is less evident in this select population of patients with advanced HF referred to a HF clinic.
n (%)
Severe
ModerateSevere
Moderate
MildModerate
Mild
None/Trace
24 (4.3%) 54%
70 (12.5%) 23%
122 (21.9%) 24%
66 (11.8%) 21%
218 (39.1%) 19%
58 (10.4%) 12%
NYHA IV*(%) Ischemic 54% 67% 59% 48% 52% Etiology(%) Ejection 18 ⫾ 5 19 ⫾ 7 21 ⫾ 7 21 ⫾ 7 23 ⫾ 9 Fraction*(%) LV dimension* 72 ⫾ 8 67 ⫾ 10 65 ⫾ 12 67 ⫾ 12 65 ⫾ 9 (mm) ERO* (cm2) 0.49 ⫾ 0.20 0.30 ⫾ 0.09 0.22 ⫾ 0.07 0.17 ⫾ 0.07 0.12 ⫾ 0.05 Regurgitant 66 ⫾ 24 43 ⫾ 12 33 ⫾ 9 27 ⫾ 9 18 ⫾ 6 volume* (ml)
43% 24 ⫾ 8 64 ⫾ 11 na na
*indicates significant correlation of parameter with severity of FMR.
157
158
Peri-Transplant Graft Dysfunction Is Associated with Ischemic Injury/Fibrosis and Adverse Long-term Outcome Mohamad H. Yamani,1 Randall C. Starling,1 Ann McNeil,1 Daniel J. Cook,2 Norman B. Ratliff,3 Ashraf Abdo,2 Janet Dempsey,1 Robert Hobbs,1 Gustavo Rincon,1 Corinne Bott-Silverman,1 Patrick M. McCarthy,4 James B. Young1—1Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH; 2Allogen Laboratory, Cleveland Clinic Foundation, Cleveland, OH; 3Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, OH; 4Cardiothoracic Surgery, Cleveland Clinic Foundation, Cleveland, OH
Surgical Ventricular Restoration in Post-Infarction Cardiomyopathy: Effects on Pressure/Volume Relationship Marisa Di Donato,1 Anna Toso,1 Lorenzo Menicanti,2 Fabio Fantini,1 Toni Badia,2 Vincent Dor3—1Dipartimento Area Critica Medico-Chirurgica, Universita di Firenze, Florence, Italy; 2Centro Cardiovascolare Malan, Istituto Policlinico San Donato, San Donato Milanese, Italy; 3Centre Cardio-Thoracic De Monaco, Centre Cardio-Thoracic De Monaco, Monaco, Monaco
Background: The main causes of graft failure after cardiac transplantation are primary graft dysfunction, intractable acute rejection, and coronary vasculopathy. Objectives: Evaluate the relationship between peri-transplant graft dysfunction and ischemic injury/fibrosis and its impact on survival. Methods: Between January 1990 and June 2002, 858 patients underwent cardiac transplantation. Eighty eight (10.2%) patients had evidence of left ventricular dysfunction (Ejection fraction ⱕ40%) within 1 week of transplant (Graft dysfunction group, GD). These were compared to the remaining cohort (770 patients) who had normal peri-transplant left ventricular function (Control). All patients underwent serial endomyocardial biopsies (average 13 biopsies during the first year) and annual coronary angiograms. Results: The Baseline characteristics between the two groups were similar in relation to age, gender, ischemia time, and etiology of heart failure. However, more patients in the GD group had pre-transplant support with left ventricular assist devices than Control (35% vs 21%, P ⬍ 0.01) reflecting the severity of the underlying disease process. Acute vascular rejection was increased in the GD group compared to Control (19% vs 6%, P ⬍ 0.001). Ischemic injury (manifested histologically by myocyte necrosis), within 2 weeks of transplant, was also more common in the GD group than in Control (38% vs 22%, P ⬍ 0.01). Further, patients in the GD group were more likely than Control to develop interstitial myocardial fibrosis within 4 weeks of transplant (19% vs 9%, P ⬍ 0.01). Compared to Control, the GD group had worse Kaplan Meier 10-year survival (37% vs 60%, P ⫽ 0.016). Conclusions: Peri-transplant graft dysfunction is associated with increased ischemic injury/fibrosis and poor survival.
Background: There is evidence that surgical ventricular restoration (SVR) for postinfarction cardiomyopathy improves ejection fraction but concern has been raised about the effective efficacy to improve left ventricular performance. Ejection fraction is in fact inadequate to assess LV performance, expecially after an intervention that drastically reduces end diastolic volume. Patients: We studied 30 post-infarction patients (58 ⫾ 8 years) who underwent SVR in order to assess LV pre-operative mechanical performance and to evaluate whether and to what extent SVR may improve it. The majority of pts had congestive heart failure (CHF) with depressed global left ventricular function (ejection fraction-EF ⫽ 30 ⫾ 13%) and extensive regional dyssynergy (dyskinesia or akinesia). Methods: LV pressure, simultaneous with LV angiography, was recorded before surgery and pre discharging, during diagnostic heart catheterization. Heart rate was paced during angiography at 100 beats/min in order to avoid differences due to cycle length between patients. LV angiograms were obtained in right anterior oblique 30º projection. Frame by frame analysis of LV angiograms simultaneous with LV pressure was performed and several hemodynamic parameters were analyzed before and after surgery. Among them: Pressure/Volume (P/V) loops, LV systolic and end systolic pressure, volumes, ejection fraction (EF) and peak filling rate (PFR). Results: Before surgery P/L loops were markedly abnormal with a narrowed area and a shifting to the right. After surgery there was an improvement in P/L loops with a significant shifting to the left and an increased area. Systolic and diastolic function improved (EF 30 ⫾ 13 to 45 ⫾ 12% p.0.001); (end diastolic volume and end systolic volume index 202 ⫾ 76 to 122 ⫾ 48 and 144 ⫾ 69 to 69 ⫾ 40 ml/m2, respectively-p 0.001 and PFR 1.75 ⫾ .7 to 2.32 ⫾ .7 p.0.0001. Conclusions: LV performance is markedly abnormal in post-infarction cardiomyopathy. The area of P/V loop represents a measure of effective external work of the ventricle and its increase after surgery, as well as its left shifting means an improvement in overall LV performance (diastolic and systolic).
156
Bridge to Heart Transplantation: A Comparison of Ventricular Assist Device and Inotropic Support Susan Moffatt,1 Michael Chan,2 Philippe Demers,1 Philip Oyer,1 Bruce Reitz,1 Robert Robbins1—1Cardiothoracic Surgery, Stanford University, Stanford, CA; 2 Cardiovascular Medicine, Stanford University, Stanford, CA
Functional Mitral Regugitation in Advanced Heart Failure Jeetendra B. Patel,1 Daniel D. Borgeson,1 Charanjit S. Rihal,1 Margaret M. Redfield1—1Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, MN
Background: Bridge to heart transplantation using ventricular assist devices (VAD) or inotropic support has traditionally been thought to be associated with poor outcomes. Patient selection and device sophistication have however improved and donor shortages often necessitate prolonged circulatory support. We therefore reviewed the outcomes of Status 2 patients and patients bridged to heart transplantation with inotropic or VAD support. Methods: Since 1984, 588 heart transplants have been performed involving: Group I: VAD-bridge to transplantation (n ⫽ 47); Group II: inotropic-bridge to transplantation (n ⫽ 148) and Group III: Status 2 patients (n ⫽ 393). The demographics of these patient groups were reviewed and survival rates calculated. Results: Group I had an average wait to transplantation of 115 days, compared to 79 days for Group II and 176 days for Group III (p ⫽ ns). The median time to first rejection episode was 37 days, 30 days and 28 days for Groups I, II and III respectively (p ⫽ ns) with all groups having the same number of rejection episodes. ICU stay and overall hospitalization was longer for Group I (9 and 31 days, respectively) compared to that of Group II and III (2 and 23 days, respectively) (p ⫽ ns). The 30 day mortality rates were 2%, 5% and 5% for Groups I, II and III, respectively with that of Group I being sigficantly less than that of both Group II and Group III (p ⬍ 0.05). The actuarial survival rates at 90 days, 1, 5 and 10 years were: Group I: 98%, 92%, 80% and 71%, Group II: 88%, 82%, 72% and 52% and Group III: 91%, 83%, 65% and 45%, respectively. These survival outomes were significantly better for the VAD-bridged group (Group I) compared to both inotropic-bridged (Group II) and Status 2 (Group III) patients (p ⬍ 0.05). Conclusions: Overall survival for patients who were bridged to heart transplantation with VAD support was significantly better compared to both Status 2 and inotrope supported patients. This improved survival was realized without a signicant increase in waiting time, ICU stay, hospital stay or rejection episodes. Therefore, at our institution, the use of a VAD as a bridge to heart transplantation has resulted in better than previously perceived outcomes.
Background: Patients with dilated cardiomyopathy develop mitral regurgitation (MR) in the absence of organic mitral valve disease (functional MR, FMR). FMR may contribute to worsening symptoms and survival in heart failure (HF) and surgical or devicebased percutaneous annuloplasty is purposed as a therapeutic strategy for patients with advanced HF. Objectives: Our objective was to define the prevalence, clinical correlates and prognostic implications of FMR and the current utilization of mitral annuloplasty in patients with advanced HF evaluated in a HF Clinic. Methods: We reviewed clinical, echocardiographic and survival data from all patients with advanced systolic HF (NYHA class III or IV; EF ⬍0.35) due to ischemic or idiopathic cardiomyopathy evaluated at Mayo HF Clinic between January 1996 and September 2001. Patients with organic mitral valve disease were excluded. Results: 558 patients met criteria and had satisfactory echocardiograms. See table. The severity of FMR was confirmed by quantitative analysis (PISA) in 88% of patients with Severe, 79% of patients with Moderate-Severe, 66% of patients with Moderate, 45% of patients with Mild-Moderate and 15% of patients with Mild FMR with calculation of effective regurgitant orifice (ERO) and regurgitant volume. Severe or Moderate–Severe tricuspid regurgitation was present in 50% of patients with Severe FMR, 33% of patients with Moderate–Severe FMR and 15% of patients with Moderate FMR. Patients with hemodynamically significant (ⱖModerate) FMR had higher mortality in univariate analysis (p ⬍ 0.03) but not when controlling for age, sex, etiology, NYHA class and EF (p ⫽ 0.67). Patients with hemodynamically significant tricuspid regurgitation had higher mortality in univariate (p ⫽ 0.002) and tended to have higher mortality in multivariate analysis (p ⫽ 0.06). Only three patients were referred for mitral valve repair subsequent to HF Clinic evaluation. Conclusion: Hemodynamically significant FMR is common among patients with advanced HF, yet surgical treatment of FMR is rarely performed. Device based therapy for FMR may expand the use of FMR reduction as a therapeutic strategy for advanced HF although concomitant tricuspid regurgitation may limit its utility. While FMR has been shown to be strongly correlated with mortality in unselected populations with systolic dysfunction or HF, correlation with mortality is less evident in this select population of patients with advanced HF referred to a HF clinic.
n (%)
Severe
ModerateSevere
Moderate
MildModerate
Mild
None/Trace
24 (4.3%) 54%
70 (12.5%) 23%
122 (21.9%) 24%
66 (11.8%) 21%
218 (39.1%) 19%
58 (10.4%) 12%
NYHA IV*(%) Ischemic 54% 67% 59% 48% 52% Etiology(%) Ejection 18 ⫾ 5 19 ⫾ 7 21 ⫾ 7 21 ⫾ 7 23 ⫾ 9 Fraction*(%) LV dimension* 72 ⫾ 8 67 ⫾ 10 65 ⫾ 12 67 ⫾ 12 65 ⫾ 9 (mm) ERO* (cm2) 0.49 ⫾ 0.20 0.30 ⫾ 0.09 0.22 ⫾ 0.07 0.17 ⫾ 0.07 0.12 ⫾ 0.05 Regurgitant 66 ⫾ 24 43 ⫾ 12 33 ⫾ 9 27 ⫾ 9 18 ⫾ 6 volume* (ml)
43% 24 ⫾ 8 64 ⫾ 11 na na
*indicates significant correlation of parameter with severity of FMR.
157
158
Peri-Transplant Graft Dysfunction Is Associated with Ischemic Injury/Fibrosis and Adverse Long-term Outcome Mohamad H. Yamani,1 Randall C. Starling,1 Ann McNeil,1 Daniel J. Cook,2 Norman B. Ratliff,3 Ashraf Abdo,2 Janet Dempsey,1 Robert Hobbs,1 Gustavo Rincon,1 Corinne Bott-Silverman,1 Patrick M. McCarthy,4 James B. Young1—1Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, OH; 2Allogen Laboratory, Cleveland Clinic Foundation, Cleveland, OH; 3Anatomic Pathology, Cleveland Clinic Foundation, Cleveland, OH; 4Cardiothoracic Surgery, Cleveland Clinic Foundation, Cleveland, OH
Surgical Ventricular Restoration in Post-Infarction Cardiomyopathy: Effects on Pressure/Volume Relationship Marisa Di Donato,1 Anna Toso,1 Lorenzo Menicanti,2 Fabio Fantini,1 Toni Badia,2 Vincent Dor3—1Dipartimento Area Critica Medico-Chirurgica, Universita di Firenze, Florence, Italy; 2Centro Cardiovascolare Malan, Istituto Policlinico San Donato, San Donato Milanese, Italy; 3Centre Cardio-Thoracic De Monaco, Centre Cardio-Thoracic De Monaco, Monaco, Monaco
Background: The main causes of graft failure after cardiac transplantation are primary graft dysfunction, intractable acute rejection, and coronary vasculopathy. Objectives: Evaluate the relationship between peri-transplant graft dysfunction and ischemic injury/fibrosis and its impact on survival. Methods: Between January 1990 and June 2002, 858 patients underwent cardiac transplantation. Eighty eight (10.2%) patients had evidence of left ventricular dysfunction (Ejection fraction ⱕ40%) within 1 week of transplant (Graft dysfunction group, GD). These were compared to the remaining cohort (770 patients) who had normal peri-transplant left ventricular function (Control). All patients underwent serial endomyocardial biopsies (average 13 biopsies during the first year) and annual coronary angiograms. Results: The Baseline characteristics between the two groups were similar in relation to age, gender, ischemia time, and etiology of heart failure. However, more patients in the GD group had pre-transplant support with left ventricular assist devices than Control (35% vs 21%, P ⬍ 0.01) reflecting the severity of the underlying disease process. Acute vascular rejection was increased in the GD group compared to Control (19% vs 6%, P ⬍ 0.001). Ischemic injury (manifested histologically by myocyte necrosis), within 2 weeks of transplant, was also more common in the GD group than in Control (38% vs 22%, P ⬍ 0.01). Further, patients in the GD group were more likely than Control to develop interstitial myocardial fibrosis within 4 weeks of transplant (19% vs 9%, P ⬍ 0.01). Compared to Control, the GD group had worse Kaplan Meier 10-year survival (37% vs 60%, P ⫽ 0.016). Conclusions: Peri-transplant graft dysfunction is associated with increased ischemic injury/fibrosis and poor survival.
Background: There is evidence that surgical ventricular restoration (SVR) for postinfarction cardiomyopathy improves ejection fraction but concern has been raised about the effective efficacy to improve left ventricular performance. Ejection fraction is in fact inadequate to assess LV performance, expecially after an intervention that drastically reduces end diastolic volume. Patients: We studied 30 post-infarction patients (58 ⫾ 8 years) who underwent SVR in order to assess LV pre-operative mechanical performance and to evaluate whether and to what extent SVR may improve it. The majority of pts had congestive heart failure (CHF) with depressed global left ventricular function (ejection fraction-EF ⫽ 30 ⫾ 13%) and extensive regional dyssynergy (dyskinesia or akinesia). Methods: LV pressure, simultaneous with LV angiography, was recorded before surgery and pre discharging, during diagnostic heart catheterization. Heart rate was paced during angiography at 100 beats/min in order to avoid differences due to cycle length between patients. LV angiograms were obtained in right anterior oblique 30º projection. Frame by frame analysis of LV angiograms simultaneous with LV pressure was performed and several hemodynamic parameters were analyzed before and after surgery. Among them: Pressure/Volume (P/V) loops, LV systolic and end systolic pressure, volumes, ejection fraction (EF) and peak filling rate (PFR). Results: Before surgery P/L loops were markedly abnormal with a narrowed area and a shifting to the right. After surgery there was an improvement in P/L loops with a significant shifting to the left and an increased area. Systolic and diastolic function improved (EF 30 ⫾ 13 to 45 ⫾ 12% p.0.001); (end diastolic volume and end systolic volume index 202 ⫾ 76 to 122 ⫾ 48 and 144 ⫾ 69 to 69 ⫾ 40 ml/m2, respectively-p 0.001 and PFR 1.75 ⫾ .7 to 2.32 ⫾ .7 p.0.0001. Conclusions: LV performance is markedly abnormal in post-infarction cardiomyopathy. The area of P/V loop represents a measure of effective external work of the ventricle and its increase after surgery, as well as its left shifting means an improvement in overall LV performance (diastolic and systolic).