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Outcomes of US Patients with Marfans Syndrome Listed for Heart Transplantation
Abstracts S393 Results: The cohort included 129 males (80%) with a mean age of 50 years (+/- 14.5), mean EF of 60% (+/- 6) and mean PWP of 11.5 mmHg (+/- 5). We found no correlation between the PWP and the e/e’ ratio (P0.16). An e/e’ cut-off value of > 14 could not predict an elevated PWP of 15 mmHg or higher (P= 0.35). There was no linear relationship between the calculated (ePWP) and the measured PWP (P= 0.25). Conclusion: The echocardiogram-based e/e’ ratio should not be used to predict an elevated PWP in patients post cardiac transplantation.
1( 208) Does Type of Mechanical Circulatory Support Influence Stroke Risk in the Perioperative Post Transplant Period? N. Nair ,1 S. Yang,2 E. Gongora.3 1Cardiology, Texas Tech Health Sciences Center, Lubbock, TX; 2Internal Medicine, Texas Tech Health Sciences Center, Lubbock, TX; 3Cardiothoracic Surgery, Memorial Cardiac and Vascular Institute, Hollywood, FL. Purpose: Stroke risk during the perioperative post-transplant period in patients bridged with mechanical circulatory support is not well-defined. This study was undertaken to assess if the type of circulatory support device used has an impact on stroke risk in this population. Methods: The study cohort of 4783 patients (≥ 18 years of age) bridged with mechanical circulatory support to cardiac transplant were derived from the UNOS/OPTN transplant registry data from 2005-2015. Data was obtained through a formal request. The study cohort was divided into 4 groups (Left Ventricular Assist Device (LVAD), Right Ventricular Assist Device (RVAD), Extracorporeal Membrane Oxygenation (ECMO) and Total Artificial Heart (TAH) depending on the type of support used to bridge to transplant. Risk factors assessed were age, gender, ischemic time, diabetes in recipient, presence of VAD at listing to transplant and use of mechanical ventilation prior to transplant. Descriptive statistics were used to describe the characteristics of the study cohort. Univariate logistic regression was used to test if there is a significant association between stroke event and all the potential risk factors. Multiple logistic regression was used to test such associations while adjusting for all other risk factors. Odds ratios (ORs) and their 95% confidence intervals (CIs) presented in parenthesis were calculated to evaluate these associations. p< 0.05 was considered significant. Results: Patients on ECMO had the highest risk of stroke immediate post transplant prior to discharge (OR 3.03, {1.16, 7.95}) followed by TAH (OR 2.03, {1.01, 4.07) as compared to those only on a LVAD(p< 0.05). Ischemic time (OR 1.3 {1.09, 1.45}) and diabetes (OR 1.8 {1.29, 2.51}) were significant risk factors (p< 0.05) in this population. Conclusion: Patients on ECMO and TAH had a 203 % and 103% increase respectively in the odds of having a stroke prior to discharge as compared to those on LVADS only. Stroke risk in patients on CF-LVADs (Heartmate II, Heatware) versus pVAD (Thoratec pVAD) did not show any significant differences. The exact mechanisms underlying such differences warrant further investigation. It is possible that factors such as diabetes and ischemic time contribute to vascular pathology in this population.
1( 209) American Population Derived Donor Score System Assessment in a Brazilian Heart Transplantation Cohort L.L. Escossia , M.G. Bonatto, M.H. Tonin, S. Mangini, F. MarcondesBraga, F. Bacal, M.S. Avila, I. Wosniak, L. Seguro, A.C. Dutra, A.R. de Paulo, J.L. Melo, F. Barone. Heart Transplant - Incor, Incor - Medicine University of São Paulo, São Paulo, Brazil. Purpose: Background: Heart transplantation (HT) is the gold standard therapy for end-stage heart failure. Scoring systems based on donor factors are scarce to predict mortality in HT. Identifying donor factors that impact survival after HT could improve outcomes and better organ allocation. Objective: to evaluate a donor score system derived from an American population to predict mortality after HT in a Brazilian cohort. Methods: We examined a retrospective database from 110 patients who underwent HT from 2013 to 2015 in a single Brazilian center. Based on a previous study from US donor population, four variables strongly associated with mortality were analyzed (ischemic time, donor age, race mismatch, blood urea nitrogen (BUN)/creatinine ratio. Cumulative survival stratified by donor risk score was estimated using the log-rank test and a survival curve including four groups was developed. Results: 110 donors, brain death related to trauma (66,6%) and stroke (14,4%); age 29,8 years-old (+/- 9,24); mean ischemic time 175 min (+/53). Mean ratio of BUN / creatinine was 18,6 (+/-11,38). 4 groups were defined: 0-2 points (30,6%), 3-5 points (53,15%), 6-8 points (14,41%) and 9-15 points (0,9%). There was no difference in survival considering each range (average of days 0-2 points: 669; 3-5 points: 634; 6-8 points: 527; 9-15 points: 662 (p: 0.78). Conclusion: Although a strong predictor of mortality after HT in an American population, this donor risk score was not useful to predict mortality in a Brazilian HT cohort. Differences in this Brazilian cohort, including younger donors and high race miscegenation may explain these findings and put forward the development of a local donor score system.
1( 210) WITHDRAWN
1( 211) Outcomes of US Patients with Marfans Syndrome Listed for Heart Transplantation B.D. Kaufman ,1 S.E. Tierney,1 D. Bernstein,1 S.H. Chen,1 J. Dykes,1 S.A. Hollander,1 D.H. Liang,2 K. Maeda,3 J. Priest,1 O. Reinhartz,3 D.N. Rosenthal,1 C. Almond.1 1Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA; 2Medicine, Stanford University, School of Medicine, Palo Alto, CA; 3Cardiothoracic Surgery, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA.
S394
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
Purpose: Advanced heart failure may occur in patients (pts) with Marfan syndrome (MS) due to primary cardiomyopathy or secondary to ischemic complications. Concern exists regarding whether Marfan pts are suitable heart transplant (HT) candidates, as the impact of immunosuppression on progression of systemic vascular disease is unknown and limited data are available regarding outcomes. We sought to describe outcomes of pts with Marfan syndrome listed for heart transplant in the United States. Methods: All US patients listed for HT and reported to have Marfan syndrome were identified using Organ Procurement and Transplant Network data. The Kaplan Meier method was used to estimate waitlist and post-HT survival. Results: Between 1989 and 2015 there were a total of 27 pts listed for HT with a mean age at listing of 36 years (S.D. ±15), 12 (44%) were ≤ 30 at listing including 5 children (age 7, 11, 14, 17 and 17). The mean weight was 72 kg (±18), height 184 cm (±18) and BSA 1.9 (±0.4). 78% were male, 48% had blood type O. Aortic surgery was reported in 5 pts (19%) prior to listing. Waitlist support was inotropes in 5 and an LVAD (Heartmate II) in one. Mean waitlist time was 199±259 days. Overall, 18 (66%) pts survived to heart transplant. Post-HT, one, three and 5-year survival were 89%, 72%, and 72%, respectively and was not different from pts transplanted without Marfan syndrome (P= 0.71) (Figure). Conclusion: Among pts with Marfan syndrome listed for heart transplant, two-thirds survived. Of those who underwent transplant, 5-year survival was relatively favorable and similar to non-Marfan pts. Heart transplant may be a suitable treatment option for selected people with Marfan syndrome and advanced heart failure.
Results: The 30-day, 1-year, 5-year survival rates were 98.1%, 96.1% and 89.7%. There was no difference between two groups in survival and immediate postoperative complication rate. On echocardiographic evaluation, size of left atrium is larger in modified group (51±9.6 vs 45±9.4, p= 0.003). There was one incidence of moderate to severe tricuspid valve regurgitation in modified group (n= 1, 2.7%). Both superior vena cava ratio (1.07±0.13 vs 1.28±0.32, p= 0.001) and inferior vena cava ratio (1.06±0.07 vs 1.13±0.19, p= 0.009) are higher in the conventional group, which means more stenotic imaging finding was observed in conventional group (Figure). However, there have been no episode of anastomosis site stenosis required intervention. Conclusion: Heart transplantation with modified bicaval anastomosis represents an attractive alternative to the conventional bicaval technique with easy to orientation and equivocal outcomes, especially in the case of small donor.
1( 213) Outcome of HVAD Bridged to Transplantation Patients After Heart Transplantation - A Single Center Experience R. Moayedifar ,1 D. Zimpfer,1 D. Wiedemann,1 J. Riebandt,1 K. Dimitrov,1 T. Schlöglhofer,2 T. Haberl,1 A. Aliabadi,1 E. Osorio,1 K. Freystaetter,1 K. Uyanik-Uenal,1 G. Laufer,1 A. Zuckermann.1 1Cardiac Surgery, Vienna General Hospital, Vienna, Austria; 2Center for Medical Physics and Biomedical Engineering, Vienna General Hospital, Vienna, Austria.
1( 212) Modified Bicaval Technique in Orthotopic Heart Transplantation: Comparison with Conventional Bicaval Technique H. Kim ,1 S. Jung,1 J. Kim,2 T. Yun,1 J. Lee.1 1Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea, Republic of; 2Department of Cardiology, Asan Medical Center, Seoul, Korea, Republic of. Purpose: The modification of bicaval anastomois was introduced as alternative of conventional technique with possibility to reduce a caliber mismatch and stricture. The objective of this study was to investigate clinical differences between these two techniques. Methods: Between January 2009 and June 2013, a total of 155 consecutive patients underwent heart transplantation with modified or conventional bicaval technique. Discrepancy in the size of vena cava compared with that of anastomosis site was assessed using enhanced computed tomography before discharge about one month after surgery. Mean follow up duration was 55.7±17.6 months.
Purpose: In recent years, the number of heart-transplant patients bridged to transplantation by Left Ventricular Assist Devices has increased to 37% (ISHLT registry 2015). This is despite data that suggests mechanically supported recipients suffer inferior mortality rates after transplantation. While studies have been published reporting the differences between the outcomes of pulsatile and continuous flow devices, including specifically the HeartMate II, no data has been reported on the outcome of HeartWare HVAD devices. We report our experience with the HeartWare HVAD LVAD in bridged to transplantation recipients after heart transplantation. Methods: We retrospectively reviewed the data of 50 patients who were bridged to transplantation with the HeartWare HVAD, and afterwards underwent heart transplantation between April 2007 and March 2016 at Vienna Cardiac Transplant Center. Comparisons are drawn from a control group composed of 276 patients who did not require LVAD support prior to transplantation in the same time period. Study endpoints were recipient and donor demographics, operative outcome, long-term survival and incidence of adverse events, defined as rejection, infection and graft vasculopathy. Results: Baseline patient characteristics were comparable between both groups. At 30% and 30.4% respectively, both groups listed a comparable number of patients as high-urgency (HU). Median duration of HVAD-support was 563 ± 392 days (25-75%: 302-830). High panel reactive antibody activity (PRA> 10%) prior to transplantation was observed in only two (4%) LVAD-patients. Post-transplant 30-day mortality rate in HVAD patients was 0% compared to 3.4% in non-LVAD patients (p= 0.1865). One-year survival for each group was 92% and 88.2% (p= 0.4341) respectively. There was no significant difference in overall-survival between HVAD (88.2%) and nonLVAD recipients (72%; p= 0.1409).
1( 208) Does Type of Mechanical Circulatory Support Influence Stroke Risk in the Perioperative Post Transplant Period? N. Nair ,1 S. Yang,2 E. Gongora.3 1Cardiology, Texas Tech Health Sciences Center, Lubbock, TX; 2Internal Medicine, Texas Tech Health Sciences Center, Lubbock, TX; 3Cardiothoracic Surgery, Memorial Cardiac and Vascular Institute, Hollywood, FL. Purpose: Stroke risk during the perioperative post-transplant period in patients bridged with mechanical circulatory support is not well-defined. This study was undertaken to assess if the type of circulatory support device used has an impact on stroke risk in this population. Methods: The study cohort of 4783 patients (≥ 18 years of age) bridged with mechanical circulatory support to cardiac transplant were derived from the UNOS/OPTN transplant registry data from 2005-2015. Data was obtained through a formal request. The study cohort was divided into 4 groups (Left Ventricular Assist Device (LVAD), Right Ventricular Assist Device (RVAD), Extracorporeal Membrane Oxygenation (ECMO) and Total Artificial Heart (TAH) depending on the type of support used to bridge to transplant. Risk factors assessed were age, gender, ischemic time, diabetes in recipient, presence of VAD at listing to transplant and use of mechanical ventilation prior to transplant. Descriptive statistics were used to describe the characteristics of the study cohort. Univariate logistic regression was used to test if there is a significant association between stroke event and all the potential risk factors. Multiple logistic regression was used to test such associations while adjusting for all other risk factors. Odds ratios (ORs) and their 95% confidence intervals (CIs) presented in parenthesis were calculated to evaluate these associations. p< 0.05 was considered significant. Results: Patients on ECMO had the highest risk of stroke immediate post transplant prior to discharge (OR 3.03, {1.16, 7.95}) followed by TAH (OR 2.03, {1.01, 4.07) as compared to those only on a LVAD(p< 0.05). Ischemic time (OR 1.3 {1.09, 1.45}) and diabetes (OR 1.8 {1.29, 2.51}) were significant risk factors (p< 0.05) in this population. Conclusion: Patients on ECMO and TAH had a 203 % and 103% increase respectively in the odds of having a stroke prior to discharge as compared to those on LVADS only. Stroke risk in patients on CF-LVADs (Heartmate II, Heatware) versus pVAD (Thoratec pVAD) did not show any significant differences. The exact mechanisms underlying such differences warrant further investigation. It is possible that factors such as diabetes and ischemic time contribute to vascular pathology in this population.
1( 209) American Population Derived Donor Score System Assessment in a Brazilian Heart Transplantation Cohort L.L. Escossia , M.G. Bonatto, M.H. Tonin, S. Mangini, F. MarcondesBraga, F. Bacal, M.S. Avila, I. Wosniak, L. Seguro, A.C. Dutra, A.R. de Paulo, J.L. Melo, F. Barone. Heart Transplant - Incor, Incor - Medicine University of São Paulo, São Paulo, Brazil. Purpose: Background: Heart transplantation (HT) is the gold standard therapy for end-stage heart failure. Scoring systems based on donor factors are scarce to predict mortality in HT. Identifying donor factors that impact survival after HT could improve outcomes and better organ allocation. Objective: to evaluate a donor score system derived from an American population to predict mortality after HT in a Brazilian cohort. Methods: We examined a retrospective database from 110 patients who underwent HT from 2013 to 2015 in a single Brazilian center. Based on a previous study from US donor population, four variables strongly associated with mortality were analyzed (ischemic time, donor age, race mismatch, blood urea nitrogen (BUN)/creatinine ratio. Cumulative survival stratified by donor risk score was estimated using the log-rank test and a survival curve including four groups was developed. Results: 110 donors, brain death related to trauma (66,6%) and stroke (14,4%); age 29,8 years-old (+/- 9,24); mean ischemic time 175 min (+/53). Mean ratio of BUN / creatinine was 18,6 (+/-11,38). 4 groups were defined: 0-2 points (30,6%), 3-5 points (53,15%), 6-8 points (14,41%) and 9-15 points (0,9%). There was no difference in survival considering each range (average of days 0-2 points: 669; 3-5 points: 634; 6-8 points: 527; 9-15 points: 662 (p: 0.78). Conclusion: Although a strong predictor of mortality after HT in an American population, this donor risk score was not useful to predict mortality in a Brazilian HT cohort. Differences in this Brazilian cohort, including younger donors and high race miscegenation may explain these findings and put forward the development of a local donor score system.
1( 210) WITHDRAWN
1( 211) Outcomes of US Patients with Marfans Syndrome Listed for Heart Transplantation B.D. Kaufman ,1 S.E. Tierney,1 D. Bernstein,1 S.H. Chen,1 J. Dykes,1 S.A. Hollander,1 D.H. Liang,2 K. Maeda,3 J. Priest,1 O. Reinhartz,3 D.N. Rosenthal,1 C. Almond.1 1Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA; 2Medicine, Stanford University, School of Medicine, Palo Alto, CA; 3Cardiothoracic Surgery, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA.
S394
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
Purpose: Advanced heart failure may occur in patients (pts) with Marfan syndrome (MS) due to primary cardiomyopathy or secondary to ischemic complications. Concern exists regarding whether Marfan pts are suitable heart transplant (HT) candidates, as the impact of immunosuppression on progression of systemic vascular disease is unknown and limited data are available regarding outcomes. We sought to describe outcomes of pts with Marfan syndrome listed for heart transplant in the United States. Methods: All US patients listed for HT and reported to have Marfan syndrome were identified using Organ Procurement and Transplant Network data. The Kaplan Meier method was used to estimate waitlist and post-HT survival. Results: Between 1989 and 2015 there were a total of 27 pts listed for HT with a mean age at listing of 36 years (S.D. ±15), 12 (44%) were ≤ 30 at listing including 5 children (age 7, 11, 14, 17 and 17). The mean weight was 72 kg (±18), height 184 cm (±18) and BSA 1.9 (±0.4). 78% were male, 48% had blood type O. Aortic surgery was reported in 5 pts (19%) prior to listing. Waitlist support was inotropes in 5 and an LVAD (Heartmate II) in one. Mean waitlist time was 199±259 days. Overall, 18 (66%) pts survived to heart transplant. Post-HT, one, three and 5-year survival were 89%, 72%, and 72%, respectively and was not different from pts transplanted without Marfan syndrome (P= 0.71) (Figure). Conclusion: Among pts with Marfan syndrome listed for heart transplant, two-thirds survived. Of those who underwent transplant, 5-year survival was relatively favorable and similar to non-Marfan pts. Heart transplant may be a suitable treatment option for selected people with Marfan syndrome and advanced heart failure.
Results: The 30-day, 1-year, 5-year survival rates were 98.1%, 96.1% and 89.7%. There was no difference between two groups in survival and immediate postoperative complication rate. On echocardiographic evaluation, size of left atrium is larger in modified group (51±9.6 vs 45±9.4, p= 0.003). There was one incidence of moderate to severe tricuspid valve regurgitation in modified group (n= 1, 2.7%). Both superior vena cava ratio (1.07±0.13 vs 1.28±0.32, p= 0.001) and inferior vena cava ratio (1.06±0.07 vs 1.13±0.19, p= 0.009) are higher in the conventional group, which means more stenotic imaging finding was observed in conventional group (Figure). However, there have been no episode of anastomosis site stenosis required intervention. Conclusion: Heart transplantation with modified bicaval anastomosis represents an attractive alternative to the conventional bicaval technique with easy to orientation and equivocal outcomes, especially in the case of small donor.
1( 213) Outcome of HVAD Bridged to Transplantation Patients After Heart Transplantation - A Single Center Experience R. Moayedifar ,1 D. Zimpfer,1 D. Wiedemann,1 J. Riebandt,1 K. Dimitrov,1 T. Schlöglhofer,2 T. Haberl,1 A. Aliabadi,1 E. Osorio,1 K. Freystaetter,1 K. Uyanik-Uenal,1 G. Laufer,1 A. Zuckermann.1 1Cardiac Surgery, Vienna General Hospital, Vienna, Austria; 2Center for Medical Physics and Biomedical Engineering, Vienna General Hospital, Vienna, Austria.
1( 212) Modified Bicaval Technique in Orthotopic Heart Transplantation: Comparison with Conventional Bicaval Technique H. Kim ,1 S. Jung,1 J. Kim,2 T. Yun,1 J. Lee.1 1Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea, Republic of; 2Department of Cardiology, Asan Medical Center, Seoul, Korea, Republic of. Purpose: The modification of bicaval anastomois was introduced as alternative of conventional technique with possibility to reduce a caliber mismatch and stricture. The objective of this study was to investigate clinical differences between these two techniques. Methods: Between January 2009 and June 2013, a total of 155 consecutive patients underwent heart transplantation with modified or conventional bicaval technique. Discrepancy in the size of vena cava compared with that of anastomosis site was assessed using enhanced computed tomography before discharge about one month after surgery. Mean follow up duration was 55.7±17.6 months.
Purpose: In recent years, the number of heart-transplant patients bridged to transplantation by Left Ventricular Assist Devices has increased to 37% (ISHLT registry 2015). This is despite data that suggests mechanically supported recipients suffer inferior mortality rates after transplantation. While studies have been published reporting the differences between the outcomes of pulsatile and continuous flow devices, including specifically the HeartMate II, no data has been reported on the outcome of HeartWare HVAD devices. We report our experience with the HeartWare HVAD LVAD in bridged to transplantation recipients after heart transplantation. Methods: We retrospectively reviewed the data of 50 patients who were bridged to transplantation with the HeartWare HVAD, and afterwards underwent heart transplantation between April 2007 and March 2016 at Vienna Cardiac Transplant Center. Comparisons are drawn from a control group composed of 276 patients who did not require LVAD support prior to transplantation in the same time period. Study endpoints were recipient and donor demographics, operative outcome, long-term survival and incidence of adverse events, defined as rejection, infection and graft vasculopathy. Results: Baseline patient characteristics were comparable between both groups. At 30% and 30.4% respectively, both groups listed a comparable number of patients as high-urgency (HU). Median duration of HVAD-support was 563 ± 392 days (25-75%: 302-830). High panel reactive antibody activity (PRA> 10%) prior to transplantation was observed in only two (4%) LVAD-patients. Post-transplant 30-day mortality rate in HVAD patients was 0% compared to 3.4% in non-LVAD patients (p= 0.1865). One-year survival for each group was 92% and 88.2% (p= 0.4341) respectively. There was no significant difference in overall-survival between HVAD (88.2%) and nonLVAD recipients (72%; p= 0.1409).