Relationship between Pulsatility Index and Volume Status in Patients with Left Ventricular Assist Devices

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Journal of Cardiac Failure Vol. 24 No. 8S August 2018

Figure 1. Kaplan-Meier estimates of mortality stratified by Class I antibodies > 25% versus Class I antibiodies  25%.

299 298 Role of Class I and Class II Panel Reactive Antibodies in Predicting Post-Heart Transplant Rejection and Survival in the Current Era. Steffne J. Kunnirickal, Lavanya Bellumkonda; Yale University, New Haven, CT Introduction: Patients with elevated panel reactive antibodies (PRA) have longer waitlist times and worse outcomes post-transplant. PRAs are now better characterized with newer detection techniques and are classified as Class I and Class II antibodies. The prognostic role of Class I and Class II antibodies is currently unknown. Hypothesis: Elevated Class I and Class II may not have the same prognostic implications. Methods: Retrospective analysis of data reported to UNOS/OPTN registry for heart transplants between 2004 and 2015 was performed. All patients over the age of 18 were included in the study. Patients with missing PRA data and those with prior heart transplantation were excluded. Impact of Class I and Class II antibodies on treated rejection at one year and overall long-term survival was evaluated. Results: Our cohort consisted of 17, 460 patients; of these 75.1% were male and 24.9% female. The mean age at transplant was 52.8 §12.6 years. Class I PRA was 25% in 15,816 (90.6%) patients and ˃25% in 1600 (9.2%) patients. Class II PRA was  25% in 16,266 (93.2%) and ˃ 25% in 1121 (6.4%) patients. Multivariate analysis based on predictors identified in univariate analysis showed that recipient age, gender, year of transplantation, HLA mismatch and Class 2 antibodies ˃ 25% were predictive of treated rejection at one year. Similar analysis showed that recipient age, donor age, ischemic time, year of transplantation and Class I antibodies ˃ 25% were predictive of long-term survival (Figure 1). Of these, elevated Class I antibodies was the strongest predictor of mortality with a hazard ratio of 25%. Conclusions: Elevated Class I and Class II antibodies impact outcomes very differently. While higher Class II antibodies are associated with increased treated rejection at one year, higher Class I antibodies are associated with increased long-term mortality.

Relationship between Pulsatility Index and Volume Status in Patients with Left Ventricular Assist Devices Marta Alhama-Belotto, Amitabh Pandey, Rajeev Mohan, J. Thomas Heywood, Ajay Srivastava; Scripps Clinic, San Diego, CA Introduction: Volume overload continues to be a common complication after left ventricular assist device (LVAD) implantation due to years of heart failure complicated with pulmonary hypertension, right ventricle dysfunction and poor nutritional status. In fact, fluctuation in volume status is one of the most dynamic parameters in patients with LVADs and becomes one of the key components of the routine clinical evaluation in these patients. We hypothesize that postural changes in the pulsatility index (PI) may be an accurate non-invasive measure of volume status that can potentially be easily used in clinic or by patients at home to adjust their fluid intake and diuretics. Methods: We included patients at least 1 month post-LVAD implantation being followed in the Advance Heart Failure Clinic at Scripps Clinic. We excluded patients unable to stand for at least 10 minutes or too unstable to cooperate. We measured systolic (SBP), diastolic and mean (MAP) blood pressure, heart rate and LVAD parameters including PI supine and after 2 minutes of standing. Supine and standing inferior vena cava (IVC) assessment was performed by bedside echocardiography. All measurements were obtained within 1 hour with no interval intervention. Results: We included 20 patients status post continuous flow LVAD. Mean time from implant was 947.5 days (range 55 - 2533 days). We were able to obtain both supine and standing echocardiograms for IVC assessment in 14 (70%) patients. We found a positive and significant correlation between postural changes in PI and postural changes in IVC (R= 0.61, p = 0.02). There were no significant changes in supine and standing SBP and MAP (SBP: 101 § 10 and 100 § 10 mmHg, p=0.59; MAP: 82 § 6 and 85 § 7 mmHg, p=0.13). We did not find a statistically significant correlation between postural changes in PI and postural changes in MAP (r = 0.15, p = 0.55). Five patients (25%) had positive orthostatic vital signs and 14 (70%) had documented PI events the days prior to the study inclusion. There was a trend for larger postural PI changes in patients with positive orthostatic vital signs or PI events, although this did not reach statistical significance (p = 0.88 and p = 0.79, respectively). Conclusion: Changes in LVAD PI seem to correlate with volume status rather than systemic blood pressure. There is a trend for larger postural PI changes in orthostatic patients and those with documented PI events. Postural PI change assessment could aid in the immediate bedside evaluation of volume status in LVAD patients. Furthermore, PI changes could be documented by patients remotely and used by providers for interval treatments without presentation to clinic.

The 22nd Annual Scientific Meeting  HFSA

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301 Treatment and Outcomes of Patients with International Society of Heart and Lung Transplantation (ISHLT) Grade 2 Rejection After Heart Transplant Luke Cunningham, Nishi Patel, Andy Lee, Cesar Guerrero-Miranda, Teena Sam, Staci McKean, Tariq Nisar, Joost Felius, Aayla Jamil, Shelley Hall; Baylor University Medical Center, Dallas, TX Introduction: Treatment guidelines for asymptomatic acute cellar rejection of ISHLT grade 2 (2R ACR) are dictated by clinical judgement and patient risk. In higher risk cases, a course of intravenous (IV) corticosteroids may be recommended, while in others a short course of oral steroids is given. There is also variability in pathologic rejection grading on endomyocardial biopsy. We aimed to determine if treatment choice predicts outcomes in 2R ACR patients. Methods: We reviewed all patients with biopsy-proven 2R ACR following heart transplantation at our institution from 2012-2016. Treatment strategies were classified as IV corticosteroids or “other” (ie, pulse oral corticosteroids or adjustment of baseline immunosupprants.) These two strategies were compared for time to re-hospitalization, time to recurrence of 2R ACR, development of cardiac allograft vasculopathy or renal insufficiency, and 1-year survival. Results: Among 305 heart transplant recipients, 73 patients developed 117 separate episodes of 2R ACR. 37 patients (51%) received IV corticosteroids and were more likely to be hospitalized (24% versus 3%) for treatment. However, the two strategy groups did not differ in time to re-hospitalization (46% versus 33%, p=0.78) (Fig 1), time to recurrence (98 days versus 51 days, p=0.48), development of cardiac allograft vasculopathy (67% versus 57%, p=0.47) or renal insufficiency (58% versus 65%, p=0.634). Admission for infection was the reason for re-hospitalization in 19% vs 3% of cases. Additionally there was no difference in 1year survival (95% versus 94%, p=0.45) (Fig 2). Conclusions: While this study is limited by a small cohort, results suggests there is no significant difference in outcomes among patients treated with either aggressive IV steroids versus adjustment of oral immunosuppressants, including oral corticosteroids. Aggressive treatment may not be needed for biopsy proven 2R ACR in patients without hemodynamic compromise. Figure 1. Correlation between positional PI and IVC changes.

300 Pathophysiological Insights into Persistent Hyponatremia after LVAD Implantation Antonio Duran, M. Ahraz Hussain, Ana S. Cruz-Solbes, Tanushree Agrawal, Ashrith Guha, Arvind Bhimaraj, Jerry Estep, Barry Trachtenberg, Fahd Hussain, Myung H. Park, Imad Hussain; Houston Methodist Hospital, Houston, TX Background: Persistent hyponatremia after LVAD implantation is not uncommon in patients with end-stage heart failure (HF) and maybe associated with adverse outcomes. The etiology of hyponatremia in HF patients is multifactorial including - low cardiac output state, volume expansion, impaired free water excretion due to renal insufficiency and use of loop diuretics. It is generally thought that with restoration of hemodynamics hyponatremia would resolve after LVAD implantation. We sought to determine the etiology of persistent hyponatremia after LVAD implantation. Methods: We performed a retrospective analysis of patients with end-stage HF who received a continuous-flow LVAD and subsequently underwent right heart catheterization (RHC) to assess invasive hemodynamics and for speed optimization. Data was collected concurrently on invasive hemodynamics, medication usage and basic metabolic panel. Hyponatremia was defined as serum sodium level < 135 mEq/L. We evaluated the data for associations between hyponatremia and low cardiac output state defined by cardiac index (CI) <2.2, volume expansion defined by right atrial pressure (RAP) >12 mmHg, volume depletion defined by RAP <5 mmHg, right ventricle (RV) dysfunction as defined by a RAP to pulmonary capillary wedge pressure (PCWP) ratio >0.75 (moderate) and >1.0 (severe), partially unloaded left ventricle (LV) defined by PCWP > 15, use of angiotensin converter enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), use of loop diuretics and renal function measured by estimated glomerular filtration rate (GFR). Each of the factors were compared between patients with hyponatremia and normal sodium levels. Results: We included 143 patients in our study. RHC was performed within 6 months from LVAD implantation in 70% of the population, the median time was 199 days. Patients with hyponatremia had a mean sodium of 130.5 mEq/L compared to 139.8 mEq/L in patients with normonatremia, p-value <0.001. Hyponatremia was not associated with any of the postulated mechanisms (table 1). One-year mortality and all-cause readmissions (from time of RHC) were both higher in the hyponatremia group, p-values of 0.012 and 0.023 respectively. Discussion: Persistent hyponatremia after LVAD implantation does not appear to be related to low cardiac output state, volume expansion or depletion, RV dysfunction, use of ACEI or ARBs, loop diuretics or renal function. Hyponatremia may be an independent marker of adverse outcomes after LVAD implantation. Table 1. Factors associated with hyponatremia, univariable analysis.

Variable

Hyponatremia at RHC(N=47)

Normal sodium at RHC(N=96)

p-value

CI < 2.2 - N (%) RAP >= 12 RAP <5 RAP/PCWPa >=0.7 RAP/PCWPa >=1 Partially unloaded LV On ACEI/ARB at discharge On loop diuretics GFR - mean (SD)

7 (20.6%) 16 (47.1%) 5(14.7%) 17 (50%) 9 (26.5%) 25 (73.5% 19 (55.9%) 27 (79.4%) 62.06 (32.66)

18 (17.8%) 42 (41.2%) 15 (14.7%) 45 (44.1%) 23 (22.5%) 61 (59.8%) 44 (43.1%) 79 (77.5%) 60.41 (23.35)

0.448 0.343 0.622 0.345 0.400 0.108 0.345 0.712 0.748