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Impact of Preoperative Atrial Fibrillation on Outcomes Following Continuous Flow LVAD Implantation
Abstracts S193 transplanted pts with pDSA > 1000 (Luminex single Antigen assay) and report the outcome. Methods: In a single center 138 pts underwent primary LT from 01/10 to 11/12, mostly bilateral procedures for cystic fibrosis. 39 pts with low pDSA levels < 1000 were excluded. Pts with pDSA MFI max > 1000 underwent 6 plasmapheresis (1 pre- and 5 post-operatively) then iv Ig (2g/kg) and one administration of rituximab (375 mg/m2). They were compared with patients without pDSA. The post operative course, and the occurrence of definite or possible AMR (DSA and clinical symptoms or immunohistological criteria) were analysed in both groups. Results: Among these 99 pts, 17 pts (17%) had pDSA MFI max > 1000 (MFI 1000 to 5000, n= 10 pts; MFI 5000 to 10 000, n= 6 pts; MFI > 10 000, n= 1 pt). Seven pts had only class I pDSA, 7 only class II pDSA and 3 had both. Lymphocytotoxicity crossmatch was negative in 15 pts and falsely positive in 2 due to prior administration of rituximab. 82 pts (83%) had no pDSA . The median waiting time before LT in pDSA+ pts was 72 d [5;124]. The preoperative and intraoperative characteristics were similar between groups as the one month incidence of bleeding, pulmonary infections, cellular rejection, mechanical ventilation duration and ICU length of stay. At day 30, definite AMR didn’t occurr in pDSA+ pts but one in pDSA- pts. At 1 year no definite or possible AMR was observed in pDSA+ pts vs 4 definite AMR and 2 possible AMR in pDSA- pts. Actuarial survival at follow up was similar between groups (log rank p = 0,3). Conclusion: This strategy allows to transplant pts with pDSA with a short waiting time. This procedure is safe, associated with similar post operative course as pDSA- pts. This high risk group of pts did not develop AMR during the first year. Further studies are needed to assess maintenance therapy, long term outcome and graft survival.
5( 18) 5( 17) Impact of Preoperative Atrial Fibrillation on Outcomes Following Continuous Flow LVAD Implantation D. Stern , M. Follis, J. Nguyen, R. Bello, D. D’Alessandro, D. Goldstein. Cardiovascular and Thoracic Surgery, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. Purpose: Preoperative atrial fibrillation (AF) is a risk factor for increased complications and mortality following valvular and coronary cardiac surgery. Scarce data exists examining complication rates following left ventricular assist device (LVAD) implantation in patients with preoperative AF. We review our institutional experience with patients with preoperative AF who underwent LVAD placement to determine its impact on survival and adverse events. Methods: All patients > 18 years old implanted with continuous flow LVADs at our institution between 6/13/2006 and 4/30/2013 were prospectively entered in an IRB approved database. Data collection continued through 9/30/2013. Patients were maintained on an anticoagulation protocol targeting an INR of 2.0-2.5. Patients with preoperative AF were compared to those without AF. Continuous variables were compared using the Mann-Whitney u-test due to deviation from normality. Categorical variables were compared using Pearson chi-squared test. Results: 120 patients received continuous flow LVADs during the study period. 66 (55%) had preoperative AF while 54 (45%) did not. At baseline, the only significant difference between the groups was the incidence of preoperative CVA in patients with AF. Post-LVAD implant duration of support, length of stay, rates of hemolysis, pump thrombus and GI bleeding were similar. Post-implant neurologic events (CVA, TIA, intracranial hemorrhage) were more common in patients with preoperative AF (27.3% vs 11.1%, p-value < . 05). Mean survival was also shorter in those patients with preoperative AF and approached significance. Conclusion: There was a statistically significant increase in the incidence of neurologic events and a trend toward decreased overall survival in LVAD patients with preoperative AF. Preoperative AF should be carefully considered in risk stratification of LVAD recipients. The addition of anti-arrhythmia procedures and left atrial appendage ligation at LVAD implant may be warranted.
The Clinical Impact of Atrial Fibrillation in Patients with the HeartMate II Left Ventricular Assist Device A.D. Enriquez ,1 C. Brandon,2 P.U. Gandhi,2 A. Nair,2 A. Anyanwu,2 S.P. Pinney.2 1Brigham and Women’s Hospital, Boston, MA; 2Mount Sinai Medical Center, New York, NY. Purpose: Atrial fibrillation (AF) is common in patients with the HeartMate II (HMII) left ventricular assist device (LVAD). However, the clinical consequences of AF in this patient population are uncertain. Methods: Records of 106 patients who underwent implantation of the HMII at a single center were reviewed. The association of AF with survival, heart failure (HF) hospitalization, bleeding and thromboembolism was examined using Kaplan-Meier survival analysis and Cox proportional hazards regression. Results: Mean age was 56.6±11.4 years, 82.1% were male, 42.5% had an ischemic cardiomyopathy, 87.7% were bridge to transplantation and median length of support was 217 days (range 1-952). Twenty-one (19.8%) patients died, and 18 (17.0%) were hospitalized for HF. There were 0.75 major bleeding events and 0.28 thromboembolic events per patient year of follow-up. AF was present in 55 (51.9%) patients; 36 (34.0%) patients had paroxysmal AF and 19 (17.9%) had persistent AF. Patients with AF were more likely to be older, have chronic kidney disease and be diagnosed with HF for > 1 year. Persistent AF was an independent predictor of both increased mortality (HR, 3.22 [1.10-9.36], p= 0.032) and increased hospitalizations for HF (HR, 3.98 [1.32 - 12.02], p= 0.014). However, AF was not associated with an elevated risk of major bleeding (HR, 1.22 [0.59 - 2.51], p= 0.595) or thromboembolism (HR, 0.67 [0.25 - 1.80], p= 0.423), though patients with AF had thromboembolic events at higher international normalized ratios (2.70 ± 0.94 vs. 1.54 ± 0.34, p= 0.003). Conclusion: AF is present in half of patients with the HMII LVAD and is associated with worse outcomes despite the absence of an increased risk of bleeding and thromboembolism. 5( 19) Atrial Fibrillation in Patients Supported by Continuous-Flow Left Ventricular Assist Device A.R. Garan ,1 K.P. Mody,1 A.P. Levine,1 J. Fried,1 M. DionizovikDimanovski,1 M. Yuzefpolskaya,1 P.C. Colombo,1 H. Takayama,2 Y. Naka,2 S. Restaino,1 D.M. Mancini,1 U.P. Jorde,1 N. Uriel.1 1Medicine, Columbia University, New York, NY; 2Surgery, Columbia University, New York, NY.
5( 18) 5( 17) Impact of Preoperative Atrial Fibrillation on Outcomes Following Continuous Flow LVAD Implantation D. Stern , M. Follis, J. Nguyen, R. Bello, D. D’Alessandro, D. Goldstein. Cardiovascular and Thoracic Surgery, Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. Purpose: Preoperative atrial fibrillation (AF) is a risk factor for increased complications and mortality following valvular and coronary cardiac surgery. Scarce data exists examining complication rates following left ventricular assist device (LVAD) implantation in patients with preoperative AF. We review our institutional experience with patients with preoperative AF who underwent LVAD placement to determine its impact on survival and adverse events. Methods: All patients > 18 years old implanted with continuous flow LVADs at our institution between 6/13/2006 and 4/30/2013 were prospectively entered in an IRB approved database. Data collection continued through 9/30/2013. Patients were maintained on an anticoagulation protocol targeting an INR of 2.0-2.5. Patients with preoperative AF were compared to those without AF. Continuous variables were compared using the Mann-Whitney u-test due to deviation from normality. Categorical variables were compared using Pearson chi-squared test. Results: 120 patients received continuous flow LVADs during the study period. 66 (55%) had preoperative AF while 54 (45%) did not. At baseline, the only significant difference between the groups was the incidence of preoperative CVA in patients with AF. Post-LVAD implant duration of support, length of stay, rates of hemolysis, pump thrombus and GI bleeding were similar. Post-implant neurologic events (CVA, TIA, intracranial hemorrhage) were more common in patients with preoperative AF (27.3% vs 11.1%, p-value < . 05). Mean survival was also shorter in those patients with preoperative AF and approached significance. Conclusion: There was a statistically significant increase in the incidence of neurologic events and a trend toward decreased overall survival in LVAD patients with preoperative AF. Preoperative AF should be carefully considered in risk stratification of LVAD recipients. The addition of anti-arrhythmia procedures and left atrial appendage ligation at LVAD implant may be warranted.
The Clinical Impact of Atrial Fibrillation in Patients with the HeartMate II Left Ventricular Assist Device A.D. Enriquez ,1 C. Brandon,2 P.U. Gandhi,2 A. Nair,2 A. Anyanwu,2 S.P. Pinney.2 1Brigham and Women’s Hospital, Boston, MA; 2Mount Sinai Medical Center, New York, NY. Purpose: Atrial fibrillation (AF) is common in patients with the HeartMate II (HMII) left ventricular assist device (LVAD). However, the clinical consequences of AF in this patient population are uncertain. Methods: Records of 106 patients who underwent implantation of the HMII at a single center were reviewed. The association of AF with survival, heart failure (HF) hospitalization, bleeding and thromboembolism was examined using Kaplan-Meier survival analysis and Cox proportional hazards regression. Results: Mean age was 56.6±11.4 years, 82.1% were male, 42.5% had an ischemic cardiomyopathy, 87.7% were bridge to transplantation and median length of support was 217 days (range 1-952). Twenty-one (19.8%) patients died, and 18 (17.0%) were hospitalized for HF. There were 0.75 major bleeding events and 0.28 thromboembolic events per patient year of follow-up. AF was present in 55 (51.9%) patients; 36 (34.0%) patients had paroxysmal AF and 19 (17.9%) had persistent AF. Patients with AF were more likely to be older, have chronic kidney disease and be diagnosed with HF for > 1 year. Persistent AF was an independent predictor of both increased mortality (HR, 3.22 [1.10-9.36], p= 0.032) and increased hospitalizations for HF (HR, 3.98 [1.32 - 12.02], p= 0.014). However, AF was not associated with an elevated risk of major bleeding (HR, 1.22 [0.59 - 2.51], p= 0.595) or thromboembolism (HR, 0.67 [0.25 - 1.80], p= 0.423), though patients with AF had thromboembolic events at higher international normalized ratios (2.70 ± 0.94 vs. 1.54 ± 0.34, p= 0.003). Conclusion: AF is present in half of patients with the HMII LVAD and is associated with worse outcomes despite the absence of an increased risk of bleeding and thromboembolism. 5( 19) Atrial Fibrillation in Patients Supported by Continuous-Flow Left Ventricular Assist Device A.R. Garan ,1 K.P. Mody,1 A.P. Levine,1 J. Fried,1 M. DionizovikDimanovski,1 M. Yuzefpolskaya,1 P.C. Colombo,1 H. Takayama,2 Y. Naka,2 S. Restaino,1 D.M. Mancini,1 U.P. Jorde,1 N. Uriel.1 1Medicine, Columbia University, New York, NY; 2Surgery, Columbia University, New York, NY.