Improved outcomes in patients awaiting heart transplantation: making the case that status 2 patients should not undergo transplantation

Improved outcomes in patients awaiting heart transplantation: making the case that status 2 patients should not undergo transplantation

The Journal of Heart and Lung Transplantation Volume 21, Number 1 Abstracts At each above-listed stratum of VO2 peak, transplant-free survival was b...

46KB Sizes 0 Downloads 25 Views

The Journal of Heart and Lung Transplantation Volume 21, Number 1

Abstracts

At each above-listed stratum of VO2 peak, transplant-free survival was better than 70% (pre-␤-blocker survival in those with a VO2 peak ⱕ14) and comparable to or better than the current 1-yr posttransplant survival. Multivariate regression did show VO2 peak to be an independent predictor of survival. Conclusion: Although VO2 peak remains an independent predictor of 1-yr transplant-free survival in HF patients on ␤-blockers, a VO2 peak cut-off of ⬎ or ⬍ 14 ml/kg/min may not distinguish who among HF patients on ␤-blockers would derive a survival advantage (at 1 yr) from a transplant. 40 IMPROVED OUTCOMES IN PATIENTS AWAITING HEART TRANSPLANTATION: MAKING THE CASE THAT STATUS 2 PATIENTS SHOULD NOT UNDERGO TRANSPLANTATION C.W. Yancy,1 P. Kaiser,2 J.M. DiMaio,3 M.H. Drazner,1 D. Dries,1 D.M. Meyer,3 W.S. Ring,3 1Department of Internal Medicine/Cardiology, University of Texas Southwestern Medical Center, Dallas, TX; 2St. Paul Univeristy Hospital, Dallas, TX; 3 Department of Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX Background:Advances in the treatment of heart failure have significantly improved survival in all classes of patients. Hypothesis: The use of newer therapies in the management of heart failure has led to a decrease in waiting list mortality rates. Methods: The United Network of Organ Sharing [UNOS] database was queried to determine deaths per 100 patient years in each of 3 time periods: 90-93; 94-97; and 98-00. The time periods correlate with the introduction of angiotensin converting enzyme inhibitors, 90-93; expanded use of amiodarone and/or defibrillators, 94-97; and addition of beta-blockers, 98-00. Death rates were further stratified by listing status: I and II, 90-97, and IA, IB and II, 98-00. Data were available for all US centers by UNOS regions. Results: UNOS: Deaths Per 100 Patient Years at Risk by UNOS Status Status I: Status I: Status I: Status IA: Status IB: Status 2: Status 2: Status 2: 90–93 94–97 98–00 98–00 98–00 90–93 94–97 98–00 220.4

118.1

81.4

166.8

25.4

19.2

12.9

8.6

Over the 10 year observation period, status I mortality declined 63% and Status II mortality declined 55%. The current mortality rate for Status 2 approximates the one year survival for heart transplantation. Limitations: The change to a status IB designation may have changed the acuity of status 2 patients. Conclusions: These data would suggest that waiting list mortality has declined, perhaps in response to improved medical therapy. Patients listed as status 2 candidates have a one year outcome similar to transplantation, thus the use of donor organs for patients listed as status 2 does not provide a definite one-year survival benefit. Patients listed as status 2 candidates have a one year outcome similar to transplantation, thus the use of donor organs for patients listed as status 2 does not provide a definite one-year survival benefit. 41 B-TYPE NATRIURETIC PEPTIDE PREDICTS SUDDEN DEATH IN PATIENTS WITH CHRONIC HEART FAILURE A SELECTION MODE FOR ICD IMPLANTATION? R. Berger, M. Huelsmann, K. Strecker, A. Bojic, R. Pacher, B. Stanek, Department of Cardiology, University of Vienna, Vienna, Austria

69

Background: Given the high incidence of sudden death in patients with chronic heart failure (CHF) and the efficacy of implantible cardioverter defibrillators, an appropriate tool for the prediction of sudden death is desirable. B-type natriuretic peptide (BNP) has prognostic significance in CHF and the stimuli for its production cause electrophysiological abnormalities. This study tests BNP levels as a predictor for sudden death. Methods: BNP levels, in addition to other neurohormonal, clinical and hemodynamic variables, were obtained from 452 patients with a LVEF ⬍35%. For prediction of sudden death, only survivors without HTx or a mechanical assist device and patients who died suddenly were analysed. Results: Up to 3 years, 293 patients survived without HTx or a mechanical assist device, 89 patients died and 65 patients underwent HTx. Mode of death was sudden in 44 patients (49%), while 31 patients (35%) had pump failure and 14 patients (16%) died from other causes. Univariate risk factors of sudden death were log BNP (P⫽0.0005), log N-ANP (P⫽0.003), LVEF (P⫽0.005), log N-BNP (P⫽0.006), systolic blood pressure (P⫽0.01), big endothelin (P⫽0.03), NYHA class (P⫽0.04) and diastolic blood pressure (P⬍0.05). In the multivariate model, log BNP levels were the only independent predictor for sudden death (P⫽0.0005). Using a cut-off point of log BNP ⬍2.11 (⫽130 pg/ml) Kaplan Meier sudden death free survival rates were significantly higher in patients below (99%) compared to patients above (81%) this cut-off point (P⫽0.0001). Conclusion: BNP levels are a strong, independent predictor of sudden death in patients with CHF.

42 PROLONGED CONTINUOUS OUTPATIENT PARENTERAL INOTROPIC SUPPORT IN HEART TRANSPLANT CANDIDATES WITH REVERSIBLE PULMONARY HYPERTENSION G.K. Karavolias, S.N. Adamopoulos, A.N. Manginas, C.G. Zamanika, D.A. Chilidou, S.C. Apostolopoulou, S.A. Rammos, D.V. Cokkinos, D.T. Kremastinos, P.A. Alivizatos, Cardiology and Cardiothoracic Transplantation, Onassis Cardiac Surgery Center, Athens, Greece Background: Pulmonary hypertension (PH) in advanced congestive heart failure (CHF) is associated with increased mortality after heart transplantation. Reversibility of elevated transpulmonary gradient (TPG) by pharmacologic agents predicts improved early post-transplant outcome. Aim: To study the long-term effect of Continuous Outpatient Inotropic Parenteral Support (COIPS) in pre-transplant CHF patients with reversible PH. Procedures: 53 pre-transplant pts with advanced CHF and reversible PH, receiving maximal oral tailored therapy with digoxin, diuretics and ACE inhibitors. Twenty pts received COIPS therapy via a Hickman catheter and a portable pump (11 pts: milrinone 0.5⫾0.2 mcg/kg/min, 9 pts: dobutamine 4.2⫾1.3 mcg/ kg/min). The remaining 33 pts did not accept COIPS (CNTRL group). Clinical and hemodynamic evaluation was repeated at 3-month intervals. Results: There was no difference in mortality between the 2 groups (Cox-Mantel survival analysis).