- Email: [email protected]
Low Dose Nesiritide Infusion Leads to Rapid and Sustained Improvement in Renal Function in Patients with Acute Renal Failure Early Post Cardiac Transplantation
The 13th Annual Scientific Meeting
HFSA
S55
176
178
A Novel Approach to Management of Acute Rejection with Percutaneous Ventricular Assist Device Insertion in Two Adolescent Heart Transplant Patients 1 Rakesh K. Singh1, Linda J. Addonizio , Marc Richmond1, Julie Vincent1, Alejandro 1 Torres1, Mathew Williams2,3; Division of Pediatric Cardiology, Columbia University 2 Medical Center, New York, NY; Division of Cardiothoracic Surgery, Columbia 3 University Medical Center, New York, NY; Division of Adult Cardiology, Columbia University Medical Center, New York, NY
Long-Term Outcomes of Combined Orthotopic Heart-Liver Transplantation with Complete Cardio-Pulmonary Bypass Support: A Case Series 1 Gordan Samoukovic , Amy Neville1, Nadia Giannetti2, Marcelo Cantarovich2, 1 1 Renzo Cecere ; Surgery, McGill University Health Centre, Montreal, QC, Canada; 2 Medicine, McGill University Health Centre, Montreal, QC, Canada
Cardiogenic shock refractory to pharmacological therapy requires mechanical circulatory support in heart transplant patients with acute cardiac graft rejection. Percutaneous placement of ventricular assist devices (VADs) have been described in the literature as treatment for cardiogenic shock due to myocardial infarction, severe pulmonary hypertension, postcardiotomy heart failure, recalcitrant arrhythmias and myocarditis. We report on two adolescent heart transplant patients with acute rejection who received hemodynamic support from percutaneous VADs. Patient 1 was a 66 kg, 15 year old male with isolated right ventricular dysfunction in the setting of grade 3A acute cellular rejection on endomyocardial biopsy. Despite treatment with milrinone, antithymocyte globulin, mycofenolate mofetil, and methylprednisolone, the patient had worsening end organ function and received 5 days of percutaneous right VAD support with the CentriMagÒ centrifugal blood pump (LevitronixÒ, Waltham, MA). Patient 2 was a 58 kg, 18 year old female with biventricular dysfunction in the setting of clinically suspected rejection. Despite treatment with milrinone, amiodarone, lidocaine, antithymocyte globulin, daclizumab, and methylprednisolone, the patient had intractable arrhythmias and subsequently underwent percutaneous biVAD placement with Impella Recover L.P. 2.5 microaxial blood pump left VAD (AbiomedÔ, Davers, MA) and CentriMagÒ centrifugal blood pump right VAD (LevitronixÒ, Waltham, MA) with oxygenator. The patient was weaned off the oxygenator after 3 days, and both devices were explanted after 7 days. Both patients were eventually discharged home with normal biventricular function on echocardiogram. This is the first case series we have found in the literature that demonstrates the feasibility of percutaneous ventricular support for the management of acute rejection with severe hemodynamic instability. Potential benefits of percutaneous VADs include lack of sternotomy and prompt deployment in facilities with a rapid response catheterization team. Further investigation is needed to evaluate the usefulness of percutaneous VADs in heart transplant patients with hemodynamically significant acute rejection.
177 Echo Doppler Evaluation of Left Atrial Pressure in Heart Transplant Recipients Theodore J. Maglione, Jennifer Wright, Nilamkumar Patel, Joan Gusmano, Biljana Pavlovic-Surjancev, Alain Heroux, Thriveni Sanagala; Cardiology, Loyola University Medical Center, Maywood, IL Introduction: Noninvasive evaluation of left atrial pressure is performed in the non transplant patient population using doppler echocardiography. The ratio of early mitral inflow velocity (E) and early diastolic mitral annular velocity by tissue doppler (e’) is directly proportional to pulmonary capillary wedge pressure (PCWP). Limited data is available in the transplant population regarding the applicability of E/e’ ratio. We hypothesize that the E/e’ ratio is a poor measure of left atrial pressure in transplant population. Methods: Doppler imaging was done in apical 4 chamber view. Early diastolic mitral inflow velocity (E) was determined by pulsed wave doppler. Mitral annular early diastolic velocity at the medial annulus (e’med) and lateral annulus (e’lat) were measured using tissue doppler. Average of e’ med and e’ lat was calculated as e’avg. We then calculated the ratios E/e’med, E/e’lat and E/e’avg. PCWP was measured by right heart catheterization. Correlation coefficient (r) was calculated for PCWP with the three E/ e’ ratios(E/e’med, E/e’lat and E/e’avg). Results: A total of 15 transplant patients were evaluated. Mean E was 77 6 19cm/sec, mean e’med was 8 6 2cm, mean e’lat was 13 6 5cm/sec, and mean e’avg was 8 6 3cm/sec. Mean E/e’med was 11 6 4, mean E/e’lat was 7 6 3, and mean E/e’avg was 8 6 3. Mean PCWP was 13 6 5mm. The r-value of PCWP was 0.4 for E/e’ med, 0.4 for E/e’ lat, and 0.5 for E/e’ avg. Conclusions: Typical doppler indices of left atrial pressure correlated poorly with PCWP in the heart transplant population. Therefore, routine use of these indices should be avoided for evaluation of left atrial pressure in the transplant population.
Although first described over 20 years ago, combined orthotopic heart-liver transplantation (CHLT) remains an uncommonly performed surgical procedure. Recent reports, however, suggest that CHLT is being performed with increased frequency in the United States and that outcomes are comparable to those of single organ recipients. Usually, the procedure is performed either using a sequential approach consisting of two independent procedures or as a simultaneous organ transplantation under porto-systemic veno-venous bypass. We present the results of four CHLT procedures performed, the most recent one performed twenty months ago, with complete cardiopulmonary bypass (CPB) support. We discuss the favourable long-term outcomes of this patient population, focussing on advantages of the surgical technique, immediate and long-term complications as well as immunosuppressive therapy and incidence of organ rejection.
179 Low Dose Nesiritide Infusion Leads to Rapid and Sustained Improvement in Renal Function in Patients with Acute Renal Failure Early Post Cardiac Transplantation 2 Stephen M. Chrzanowski1, Christopher Wolfe , Mariell L. Jessup1, Michael A. 1 Acker2, Joyce W. Wald1, Paul R.2 Forfia1; Medicine/Cardiovascular, University of Pennsylvania, Philadelphia, PA; Surgery/Cardiothoracic, University of Pennsylvania, Philadelphia, PA Rationale: Acute renal failure (ARF) occurs frequently early after orthotopic heart transplantation (OHT). Nesiritide (Nes) has been shown to improve hemodynamics and renal function in patients early post OHT, but its role in the treatment of clinically significant ARF in this population is unclear. We report the salutary effects of Nes on renal function in patients with ARF and relative oliguria early post OHT. Methods: We retrospectively identified 13 patients (10/06-3/09) who developed ARF early post OHT (2-14 days; median 4 days) and received continuous Nes infusion as attempted renal rescue therapy (no bolus; 0.005-0.01 mcg/kg/min). Data presented as mean6SD. yP!0.05 vs. values prior to Nes infusion. Results: The mean pre-OHT BUN/Cr was 30/1.5 mg/dl. Patients developed ARF (mean 78% increase serum Cr vs. pre-OHT; one subject had a supratherapeutic tacrolimus level (26.5; group mean 12.4 ng/ml). All subjects showed signs of clinical volume overload. Table 1 summarizes renal function at baseline (BL), on Nes (Nes), and 30 days after stopping Nes (30d). Conclusion: Low dose nesiritide infusion leads to a rapid and sustained improvement in renal function in patients with acute renal failure early post cardiac transplantation.
Patient
BUN/Cr BL
UOP BL ml/day
BUN/Cr Nes
1 39/2.5 975 2 46/2.4 330 3 79/2.8 2010 4 68/3.9 320 5 74/3.3 878 6 54/2.7 2825 7 78/2.3 2750 8 52/2.1 1450 9 77/2.2 1625 10 47/3.7 585 11 107/4.9 755 12 34/2.2 1044 13 102/3.1 1000 Mean SD 65 6 21/2.9 6 0.8 1273 6 827 67 6
UOP Nes ml/day
22/1.5 98/4.3 25/3.0 56/2.3 70/2.3 55/2.3 71/2.2 57/2.2 45/1.3 65/2.1 92/2.7 55/1.7 108/2.1 23/2.3 6 0.8y 2944
530 2945 2800 3050 5145 2005 3700 2400 1975 4525 2875 3800 2525 6 1183y
BUN/Cr 30d 26/5.9 20/1.3 83/3.8 34/2.6 22/1.1 47/2.5 30/1.3 14/1.0 18/0.8 36/2.1 28/1.0 31/1.2 N/A 32 6 18/2.0 6 1.5y
Nearly all patients were normotensive at BL (132 6 15mmHg) and during Nes infusion (122 6 19mmHg). Serum Cr improved in 10/13 subjects, while 11/13 improved their UOP on Nes. At 30 days post Nes, 11/12 subjects showed improved BUN and Cr vs. BL; mean BUN and Cr at 30 days post Nes infusion were not significantly different from pre-OHT values.
HFSA
S55
176
178
A Novel Approach to Management of Acute Rejection with Percutaneous Ventricular Assist Device Insertion in Two Adolescent Heart Transplant Patients 1 Rakesh K. Singh1, Linda J. Addonizio , Marc Richmond1, Julie Vincent1, Alejandro 1 Torres1, Mathew Williams2,3; Division of Pediatric Cardiology, Columbia University 2 Medical Center, New York, NY; Division of Cardiothoracic Surgery, Columbia 3 University Medical Center, New York, NY; Division of Adult Cardiology, Columbia University Medical Center, New York, NY
Long-Term Outcomes of Combined Orthotopic Heart-Liver Transplantation with Complete Cardio-Pulmonary Bypass Support: A Case Series 1 Gordan Samoukovic , Amy Neville1, Nadia Giannetti2, Marcelo Cantarovich2, 1 1 Renzo Cecere ; Surgery, McGill University Health Centre, Montreal, QC, Canada; 2 Medicine, McGill University Health Centre, Montreal, QC, Canada
Cardiogenic shock refractory to pharmacological therapy requires mechanical circulatory support in heart transplant patients with acute cardiac graft rejection. Percutaneous placement of ventricular assist devices (VADs) have been described in the literature as treatment for cardiogenic shock due to myocardial infarction, severe pulmonary hypertension, postcardiotomy heart failure, recalcitrant arrhythmias and myocarditis. We report on two adolescent heart transplant patients with acute rejection who received hemodynamic support from percutaneous VADs. Patient 1 was a 66 kg, 15 year old male with isolated right ventricular dysfunction in the setting of grade 3A acute cellular rejection on endomyocardial biopsy. Despite treatment with milrinone, antithymocyte globulin, mycofenolate mofetil, and methylprednisolone, the patient had worsening end organ function and received 5 days of percutaneous right VAD support with the CentriMagÒ centrifugal blood pump (LevitronixÒ, Waltham, MA). Patient 2 was a 58 kg, 18 year old female with biventricular dysfunction in the setting of clinically suspected rejection. Despite treatment with milrinone, amiodarone, lidocaine, antithymocyte globulin, daclizumab, and methylprednisolone, the patient had intractable arrhythmias and subsequently underwent percutaneous biVAD placement with Impella Recover L.P. 2.5 microaxial blood pump left VAD (AbiomedÔ, Davers, MA) and CentriMagÒ centrifugal blood pump right VAD (LevitronixÒ, Waltham, MA) with oxygenator. The patient was weaned off the oxygenator after 3 days, and both devices were explanted after 7 days. Both patients were eventually discharged home with normal biventricular function on echocardiogram. This is the first case series we have found in the literature that demonstrates the feasibility of percutaneous ventricular support for the management of acute rejection with severe hemodynamic instability. Potential benefits of percutaneous VADs include lack of sternotomy and prompt deployment in facilities with a rapid response catheterization team. Further investigation is needed to evaluate the usefulness of percutaneous VADs in heart transplant patients with hemodynamically significant acute rejection.
177 Echo Doppler Evaluation of Left Atrial Pressure in Heart Transplant Recipients Theodore J. Maglione, Jennifer Wright, Nilamkumar Patel, Joan Gusmano, Biljana Pavlovic-Surjancev, Alain Heroux, Thriveni Sanagala; Cardiology, Loyola University Medical Center, Maywood, IL Introduction: Noninvasive evaluation of left atrial pressure is performed in the non transplant patient population using doppler echocardiography. The ratio of early mitral inflow velocity (E) and early diastolic mitral annular velocity by tissue doppler (e’) is directly proportional to pulmonary capillary wedge pressure (PCWP). Limited data is available in the transplant population regarding the applicability of E/e’ ratio. We hypothesize that the E/e’ ratio is a poor measure of left atrial pressure in transplant population. Methods: Doppler imaging was done in apical 4 chamber view. Early diastolic mitral inflow velocity (E) was determined by pulsed wave doppler. Mitral annular early diastolic velocity at the medial annulus (e’med) and lateral annulus (e’lat) were measured using tissue doppler. Average of e’ med and e’ lat was calculated as e’avg. We then calculated the ratios E/e’med, E/e’lat and E/e’avg. PCWP was measured by right heart catheterization. Correlation coefficient (r) was calculated for PCWP with the three E/ e’ ratios(E/e’med, E/e’lat and E/e’avg). Results: A total of 15 transplant patients were evaluated. Mean E was 77 6 19cm/sec, mean e’med was 8 6 2cm, mean e’lat was 13 6 5cm/sec, and mean e’avg was 8 6 3cm/sec. Mean E/e’med was 11 6 4, mean E/e’lat was 7 6 3, and mean E/e’avg was 8 6 3. Mean PCWP was 13 6 5mm. The r-value of PCWP was 0.4 for E/e’ med, 0.4 for E/e’ lat, and 0.5 for E/e’ avg. Conclusions: Typical doppler indices of left atrial pressure correlated poorly with PCWP in the heart transplant population. Therefore, routine use of these indices should be avoided for evaluation of left atrial pressure in the transplant population.
Although first described over 20 years ago, combined orthotopic heart-liver transplantation (CHLT) remains an uncommonly performed surgical procedure. Recent reports, however, suggest that CHLT is being performed with increased frequency in the United States and that outcomes are comparable to those of single organ recipients. Usually, the procedure is performed either using a sequential approach consisting of two independent procedures or as a simultaneous organ transplantation under porto-systemic veno-venous bypass. We present the results of four CHLT procedures performed, the most recent one performed twenty months ago, with complete cardiopulmonary bypass (CPB) support. We discuss the favourable long-term outcomes of this patient population, focussing on advantages of the surgical technique, immediate and long-term complications as well as immunosuppressive therapy and incidence of organ rejection.
179 Low Dose Nesiritide Infusion Leads to Rapid and Sustained Improvement in Renal Function in Patients with Acute Renal Failure Early Post Cardiac Transplantation 2 Stephen M. Chrzanowski1, Christopher Wolfe , Mariell L. Jessup1, Michael A. 1 Acker2, Joyce W. Wald1, Paul R.2 Forfia1; Medicine/Cardiovascular, University of Pennsylvania, Philadelphia, PA; Surgery/Cardiothoracic, University of Pennsylvania, Philadelphia, PA Rationale: Acute renal failure (ARF) occurs frequently early after orthotopic heart transplantation (OHT). Nesiritide (Nes) has been shown to improve hemodynamics and renal function in patients early post OHT, but its role in the treatment of clinically significant ARF in this population is unclear. We report the salutary effects of Nes on renal function in patients with ARF and relative oliguria early post OHT. Methods: We retrospectively identified 13 patients (10/06-3/09) who developed ARF early post OHT (2-14 days; median 4 days) and received continuous Nes infusion as attempted renal rescue therapy (no bolus; 0.005-0.01 mcg/kg/min). Data presented as mean6SD. yP!0.05 vs. values prior to Nes infusion. Results: The mean pre-OHT BUN/Cr was 30/1.5 mg/dl. Patients developed ARF (mean 78% increase serum Cr vs. pre-OHT; one subject had a supratherapeutic tacrolimus level (26.5; group mean 12.4 ng/ml). All subjects showed signs of clinical volume overload. Table 1 summarizes renal function at baseline (BL), on Nes (Nes), and 30 days after stopping Nes (30d). Conclusion: Low dose nesiritide infusion leads to a rapid and sustained improvement in renal function in patients with acute renal failure early post cardiac transplantation.
Patient
BUN/Cr BL
UOP BL ml/day
BUN/Cr Nes
1 39/2.5 975 2 46/2.4 330 3 79/2.8 2010 4 68/3.9 320 5 74/3.3 878 6 54/2.7 2825 7 78/2.3 2750 8 52/2.1 1450 9 77/2.2 1625 10 47/3.7 585 11 107/4.9 755 12 34/2.2 1044 13 102/3.1 1000 Mean SD 65 6 21/2.9 6 0.8 1273 6 827 67 6
UOP Nes ml/day
22/1.5 98/4.3 25/3.0 56/2.3 70/2.3 55/2.3 71/2.2 57/2.2 45/1.3 65/2.1 92/2.7 55/1.7 108/2.1 23/2.3 6 0.8y 2944
530 2945 2800 3050 5145 2005 3700 2400 1975 4525 2875 3800 2525 6 1183y
BUN/Cr 30d 26/5.9 20/1.3 83/3.8 34/2.6 22/1.1 47/2.5 30/1.3 14/1.0 18/0.8 36/2.1 28/1.0 31/1.2 N/A 32 6 18/2.0 6 1.5y
Nearly all patients were normotensive at BL (132 6 15mmHg) and during Nes infusion (122 6 19mmHg). Serum Cr improved in 10/13 subjects, while 11/13 improved their UOP on Nes. At 30 days post Nes, 11/12 subjects showed improved BUN and Cr vs. BL; mean BUN and Cr at 30 days post Nes infusion were not significantly different from pre-OHT values.