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Primary Graft Dysfunction (PGD) After Heart Transplantation (HTx): Veno-Arterial ECMO as Bridge-to-Recovery?
S400
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
1( 225)
Methods: 72 patients underwent htx in our department between 2010 and 9/2016. 15 patients were treated with ECLS due to graft dysfunction, with 10 intraoperative implantations (group ECLS-I) and 5 after arrival on ICU (ECLS-P). ECLS and noECLS patients were comparable regarding pre- and intraoperative parameter. Results: In the ECLS group 6 patients died within 30 days (ECLS-I:3, ECLS-P:3). Survival at one year (n= 56) was 81.4 % (21/43) in noECLS patients compared to 61.5 % (5/13) after ECLS. The incidence of renal failure (no ECLS 18.6 % vs. 23.1 %) or of at least one graft rejection > I° (7.0 vs. 7.7 %) was comparable between both groups. Ventricular assist device before htx did not cause significant differences postoperatively between the groups. However, in addition to a higher mortality, postoperative morbidity (mechanical ventilation, inotropic support, renal failure) was also increased in patients receiving ECLS on ICU compared to those with intraoperative implantation. Conclusion: In patients with graft dysfunction after htx, ECLS represents a hemodynamic support which should be considered early in the intraoperative setting. Delayed application may significantly impair patients´outcome, more than ever in times of an increasing number of marginal donor organs.
Dose-Dependent Association Between Amiodarone and Primary Graft Dysfunction in Heart Transplantation M. Wright ,1 K. Takeda,1 C. Mauro,2 D. Jennings,1 P. Kurlansky,1 J. Han,1 L. Truby,1 S. Stein,1 V. Topkara,1 A.R. Garan,1 M. Yuzefpolskaya,1 P. Colombo,1 Y. Naka,1 M. Farr,1 H. Takayama.1 1Columbia University Medical Center, New York, NY; 2Columbia University, Mailman School of Public Health, New York, NY. Purpose: There is growing concern regarding the association between pretransplant amiodarone use and post-transplant primary graft dysfunction (PGD). We hypothesize that amiodarone use is associated with severe PGD in a dose-dependent manner. Methods: This is a retrospective review of 269 consecutive adult patients who underwent orthotopic heart transplantation (OHT) at our institution between January 1st, 2010 and December 31st, 2014. 100 were on amiodarone at the time of OHT (Group 1) and 169 were not (Group 2). Dose at the time of OHT and 6-month cumulative pre-OHT amiodarone doses were recorded. The primary outcome was severe PGD (mechanical circulatory support within 24 hours of OHT), analyzed via logistic regression adjusted for ischemic time and pre-OHT creatinine. Secondary outcomes included hospital length-ofstay (Wilcoxon signed-rank test), in-hospital mortality (logistic regression), and 4-year survival (log-rank test of Kaplan-Meier survival curves). Results: There were 27 cases (10%) of severe PGD in the entire cohort - 20 cases in group 1 (20%) and 7 cases in Group 2 (4%) (OR: 6.07, 95% CI: 2.4215.26, p < 0.001). There were 11 in-hospital deaths in Group 1 (11%) and 7 in Group 2 (4%) (OR: 2.89, 95% CI: 1.04-7.50, p = 0.04). Median hospital stay among those who survived to discharge (p = 0.1) and 4-year survival (p = 0.1) were not different. Each 100 mg increase of amiodarone on the day of OHT (OR: 1.56, 95% CI: 1.27-1.92, p < 0.001) and each 5,000 mg increase in 6-month cumulative dose (OR: 1.16, 95% CI: 1.09-1.25, p < 0.001) was associated with increased odds of developing severe PGD. Among 25 patients in Group 2 who had their amiodarone discontinued within 6 months of OHT, only 1 patient (4%) developed severe PGD (p = 0.07). Conclusion: Amiodarone use pre-OHT is an independent predictor of increased severe PGD and in-hospital mortality incidence. Additionally, increased day-of-OHT and 6-month cumulative amiodarone doses are associated with increased severe PGD incidence in a dose-dependent manner.
1( 226) Primary Graft Dysfunction (PGD) After Heart Transplantation (HTx): Veno-Arterial ECMO as Bridge-to-Recovery? U. Boeken ,1 A. Mehdiani,1 B. Sowinski,1 A. Schmidt,1 H. Dalyanoglu,1 R. Westenfeld,2 P. Akhyari,1 D. Saeed,1 A. Lichtenberg.1 1Cardiovascular Surgery, University Hospital, Duesseldorf, Germany; 2Cardiology, University Hospital, Duesseldorf, Germany. Purpose: The use of extracorporeal life support (ECLS, veno-arterial ECMO) in the early period after heart transplantation (htx) has enormously increased during the last years. Representing a very helpful, short-term device in patients with primary graft dysfunction (PGD), its consequences for the further course are still controversially discussed. We aimed to compare patients with and without ECLS early following htx.
1( 227) Reoperative Sternotomy Is Not Associated with Increased Rates of Primary Graft Dysfunction Following Cardiac Transplantation B. Lima , S. Still, A. Shaikh, G. Saracino, A.K. Jamil, J. Felius, S.M. Joseph, S.A. Hall, A.E. Rafael, J.C. MacHannaford, G.V. GonzalezStawinski. Baylor University Medical Center, Dallas, TX. Purpose: Increasingly, patients presenting for heart transplant have undergone previous cardiac procedures requiring sternotomy. The impact of reoperative sternotomy on outcomes after transplant has not been fully delineated. Here we assess prior sternotomy as a risk factor for primary graft dysfunction (PGD) using ISHLT consensus guidelines for PGD. Methods: We reviewed consecutive adult cardiac transplants performed at our center between 2012-2016. Patients with previous sternotomy (PS group) and those with no previous sternotomy (NPS group) prior to transplantation were compared in terms of baseline recipient, donor, and postoperative characteristics, with the presence of moderate or severe PGD as the primary outcome. Additionally, we evaluated 1-year survival. Results: Of 233 patients, 122 (52%) had undergone prior sternotomy. The PS group was older (58±11 vs 55±11 years; P= 0.004), more often male (83% vs 68%, P= 0.009) and more often had ischemic cardiomyopathy (64% vs 34%; P< 0.0001) before transplantation. Donor characteristics differed only slightly in BMI (29 vs 28 kg/m2, P= 0.04) and were otherwise similar. We found no significant differences in the rates of moderate to severe PGD (13% vs 11%; P= 0.69). However, the PS group had longer hospital stays (median 9.5 [7-17] vs 8 [6-12] days; P= 0.001), greater incidence of pneumonia (11% vs 2.7%; P= 0.019) than the NPS group. After adjusting for pre-transplant ECMO and listing status, the PS group was more likely to die within the first year (hazard ratio, 2.95; 95%-CI 1.19-7.3; P= 0.019) compared to the NPS group. Conclusion: Earlier reports have shown that patients with PS have increased morbidity and mortality following cardiac transplantation. The present results suggest that patients with PS may have increased risk of mortality within the first year post-transplant, however the underlying cause is not likely attributable to increased rates of PGD.
The Journal of Heart and Lung Transplantation, Vol 36, No 4S, April 2017
1( 225)
Methods: 72 patients underwent htx in our department between 2010 and 9/2016. 15 patients were treated with ECLS due to graft dysfunction, with 10 intraoperative implantations (group ECLS-I) and 5 after arrival on ICU (ECLS-P). ECLS and noECLS patients were comparable regarding pre- and intraoperative parameter. Results: In the ECLS group 6 patients died within 30 days (ECLS-I:3, ECLS-P:3). Survival at one year (n= 56) was 81.4 % (21/43) in noECLS patients compared to 61.5 % (5/13) after ECLS. The incidence of renal failure (no ECLS 18.6 % vs. 23.1 %) or of at least one graft rejection > I° (7.0 vs. 7.7 %) was comparable between both groups. Ventricular assist device before htx did not cause significant differences postoperatively between the groups. However, in addition to a higher mortality, postoperative morbidity (mechanical ventilation, inotropic support, renal failure) was also increased in patients receiving ECLS on ICU compared to those with intraoperative implantation. Conclusion: In patients with graft dysfunction after htx, ECLS represents a hemodynamic support which should be considered early in the intraoperative setting. Delayed application may significantly impair patients´outcome, more than ever in times of an increasing number of marginal donor organs.
Dose-Dependent Association Between Amiodarone and Primary Graft Dysfunction in Heart Transplantation M. Wright ,1 K. Takeda,1 C. Mauro,2 D. Jennings,1 P. Kurlansky,1 J. Han,1 L. Truby,1 S. Stein,1 V. Topkara,1 A.R. Garan,1 M. Yuzefpolskaya,1 P. Colombo,1 Y. Naka,1 M. Farr,1 H. Takayama.1 1Columbia University Medical Center, New York, NY; 2Columbia University, Mailman School of Public Health, New York, NY. Purpose: There is growing concern regarding the association between pretransplant amiodarone use and post-transplant primary graft dysfunction (PGD). We hypothesize that amiodarone use is associated with severe PGD in a dose-dependent manner. Methods: This is a retrospective review of 269 consecutive adult patients who underwent orthotopic heart transplantation (OHT) at our institution between January 1st, 2010 and December 31st, 2014. 100 were on amiodarone at the time of OHT (Group 1) and 169 were not (Group 2). Dose at the time of OHT and 6-month cumulative pre-OHT amiodarone doses were recorded. The primary outcome was severe PGD (mechanical circulatory support within 24 hours of OHT), analyzed via logistic regression adjusted for ischemic time and pre-OHT creatinine. Secondary outcomes included hospital length-ofstay (Wilcoxon signed-rank test), in-hospital mortality (logistic regression), and 4-year survival (log-rank test of Kaplan-Meier survival curves). Results: There were 27 cases (10%) of severe PGD in the entire cohort - 20 cases in group 1 (20%) and 7 cases in Group 2 (4%) (OR: 6.07, 95% CI: 2.4215.26, p < 0.001). There were 11 in-hospital deaths in Group 1 (11%) and 7 in Group 2 (4%) (OR: 2.89, 95% CI: 1.04-7.50, p = 0.04). Median hospital stay among those who survived to discharge (p = 0.1) and 4-year survival (p = 0.1) were not different. Each 100 mg increase of amiodarone on the day of OHT (OR: 1.56, 95% CI: 1.27-1.92, p < 0.001) and each 5,000 mg increase in 6-month cumulative dose (OR: 1.16, 95% CI: 1.09-1.25, p < 0.001) was associated with increased odds of developing severe PGD. Among 25 patients in Group 2 who had their amiodarone discontinued within 6 months of OHT, only 1 patient (4%) developed severe PGD (p = 0.07). Conclusion: Amiodarone use pre-OHT is an independent predictor of increased severe PGD and in-hospital mortality incidence. Additionally, increased day-of-OHT and 6-month cumulative amiodarone doses are associated with increased severe PGD incidence in a dose-dependent manner.
1( 226) Primary Graft Dysfunction (PGD) After Heart Transplantation (HTx): Veno-Arterial ECMO as Bridge-to-Recovery? U. Boeken ,1 A. Mehdiani,1 B. Sowinski,1 A. Schmidt,1 H. Dalyanoglu,1 R. Westenfeld,2 P. Akhyari,1 D. Saeed,1 A. Lichtenberg.1 1Cardiovascular Surgery, University Hospital, Duesseldorf, Germany; 2Cardiology, University Hospital, Duesseldorf, Germany. Purpose: The use of extracorporeal life support (ECLS, veno-arterial ECMO) in the early period after heart transplantation (htx) has enormously increased during the last years. Representing a very helpful, short-term device in patients with primary graft dysfunction (PGD), its consequences for the further course are still controversially discussed. We aimed to compare patients with and without ECLS early following htx.
1( 227) Reoperative Sternotomy Is Not Associated with Increased Rates of Primary Graft Dysfunction Following Cardiac Transplantation B. Lima , S. Still, A. Shaikh, G. Saracino, A.K. Jamil, J. Felius, S.M. Joseph, S.A. Hall, A.E. Rafael, J.C. MacHannaford, G.V. GonzalezStawinski. Baylor University Medical Center, Dallas, TX. Purpose: Increasingly, patients presenting for heart transplant have undergone previous cardiac procedures requiring sternotomy. The impact of reoperative sternotomy on outcomes after transplant has not been fully delineated. Here we assess prior sternotomy as a risk factor for primary graft dysfunction (PGD) using ISHLT consensus guidelines for PGD. Methods: We reviewed consecutive adult cardiac transplants performed at our center between 2012-2016. Patients with previous sternotomy (PS group) and those with no previous sternotomy (NPS group) prior to transplantation were compared in terms of baseline recipient, donor, and postoperative characteristics, with the presence of moderate or severe PGD as the primary outcome. Additionally, we evaluated 1-year survival. Results: Of 233 patients, 122 (52%) had undergone prior sternotomy. The PS group was older (58±11 vs 55±11 years; P= 0.004), more often male (83% vs 68%, P= 0.009) and more often had ischemic cardiomyopathy (64% vs 34%; P< 0.0001) before transplantation. Donor characteristics differed only slightly in BMI (29 vs 28 kg/m2, P= 0.04) and were otherwise similar. We found no significant differences in the rates of moderate to severe PGD (13% vs 11%; P= 0.69). However, the PS group had longer hospital stays (median 9.5 [7-17] vs 8 [6-12] days; P= 0.001), greater incidence of pneumonia (11% vs 2.7%; P= 0.019) than the NPS group. After adjusting for pre-transplant ECMO and listing status, the PS group was more likely to die within the first year (hazard ratio, 2.95; 95%-CI 1.19-7.3; P= 0.019) compared to the NPS group. Conclusion: Earlier reports have shown that patients with PS have increased morbidity and mortality following cardiac transplantation. The present results suggest that patients with PS may have increased risk of mortality within the first year post-transplant, however the underlying cause is not likely attributable to increased rates of PGD.