Specialized, comprehensive care eliminates racial and gender differences in mortality between African American and Caucasian heart failure patients

232

Abstracts

242 DOBUTAMINE/ATROPINE STRESS ECHOCARDIOGRAPHY: FEASIBILITY, SAFETY AND EARLY RESULTS IN PAEDIATRIC HEART TRANSPLANT RECIPIENTS A.I. Dipchand, B.W. Mccrindle, K. Lee, L.J. West, J.F. Smallhorn; Hospital for Sick Children, Toronto, Canada Purpose:a) To assess prospectively the feasibility and safety of dobutamine/atropine stress echocardiography (DSE) in paediatric heart transplant recipients, and b) To review early results in comparison to the presence of coronary artery disease by angiography and graft survival. Methods: In this prospective study, 44 DSEs were undertaken in 34 patients. Data collected included resting and peak heart rate (HR) and blood pressure, dose of dobutamine (DB), requirement for atropine (ATR), presence of changes on electrocardiogram (ECG), presence of coronary artery disease (CAD) by angiography, and patient outcome. Results: Median age at transplant was 5.6yrs (1day-16.7yrs). The median time from transplant to first DSE was 1.8yrs (0.5-10.6yrs). Looking at all 44 DSE studies, the mean dose of DB was 40⫹/-10 ug/kg/min. Atropine was required in 13 (30%). The mean double product at peak was 21683⫹/-4008 beats-mmHg/min (range 14820-30448). Target HR was achieved in 38 (86%). No ECG changes were detected in 41 (93%). 2/44 (5%) required termination; 1 for atrial flutter and 1 with asymmetric septal hypertrophy who developed a left ventricular outflow tract gradient of 100 mmHg. Looking at all 34 patients, 6/34 (18%) had an abnormal DSE with 3/5 (60%,1 pending) having CAD by angiography. 9/34 (26%) had wall motion abnormalities at rest with only 3/9 (33%) having an abnormal DSE. 7 (21%) had CAD by angiography with 3 (43%) having an abnormal DSE. All 3 deceased patients had normal DSEs and causes of death were unrelated to CAD. The 1 retransplanted patient had CAD and an abnormal DSE. 1/9 patients developed an abnormal DSE on serial study and repeat angiography is pending. 1/9 patients developed progressive worsening on serial study with progression of CAD by angiography. Conclusion: Technically adequate DSE may be performed safely in paediatric heart transplant recipients and serial DSEs may play a role in the assessment of graft CAD. Long term, sequential follow up is required to truly evaluate the impact of DSE on patient management and outcome. 243 IS RENAL FUNCTION IN PAEDIATRIC HEART TRANSPLANT RECIPIENTS INFLUENCED BY LATE REDUCTION IN CYCLOSPORINE DOSAGE? J.E. Rice, A.T. Shipp, S. Vidmar, R.G. Weintraub; Royal Children’s Hospital, Melbourne, Australia Objective: To determine the relation between Cyclosporine (CSA) dose and renal function among paediatric heart transplant recipients. Methods: A retrospective study of paediatric patients, observed for at least 3 years post-transplant, with serial measurement of renal glomerular filtration rate (GFR). Patient variables examined included pre-existing disease (cardiomyopathy or congenital heart disease), age at transplant, duration of follow-up, CSA dose and trough levels at 3 months post-transplant and yearly until latest follow-up. For each patient the least squares regression method was used to estimate the average rate of change per year (slope value) for GFR and CSA dose during follow-up. A linear

The Journal of Heart and Lung Transplantation February 2001 regression was used to predict GFR slope for a hypothetical dose slope of 0. Results: 25 patients who met the study criteria underwent transplantation at a median age of 11.7 years (interquartile range 6.8-14.5 years) and were followed for a median of 6.0 years (IR: 4 - 7). The median GFR at year 1 post-transplant was 73ml/min/1.73m2 (IR: 50 - 89) and at latest follow-up was 75ml/min/1.73m2 (IR 57 - 98). The median CSA dose and trough level at year one post-transplant were 6.1mg/kg/day and 234ng/ml, and at latest follow-up were 3.45mg/kg/ day and 141ng/ml, respectively. The overall median rate of change in GFR was ⫹1.58ml/year observation (95% CI: -0.88, 4.68) and was inversely related to measured GFR at year 1 post-transplant (r⫽0.61, p⫽0.0046). The median rate of change of GFR was unrelated to any other patient variables including CSA dose and levels at the specified time intervals, and the median rate of change of CSA dose for all patients. Extrapolating to a constant CSA dose gave a predicted rate of change in GFR of 5.9 ml/year (95%CI: -1.9, 13.8). Conclusions: Renal function in paediatric cardiac transplant recipients treated with CSA is moderately depressed at 12 months after transplantation, and does not change significantly over subsequent years. There is no evidence that renal function ⱖ 1 year posttransplant is influenced by progressive reduction in CSA dose. 244 SPECIALIZED, COMPREHENSIVE CARE ELIMINATES RACIAL AND GENDER DIFFERENCES IN MORTALITY BETWEEN AFRICAN AMERICAN AND CAUCASIAN HEART FAILURE PATIENTS S.V. Pamboukian, A. Heroux, L. Bartlett, D. Delgado, P. Meyer, E. Winkel, W. Kao, M. Saltzberg, M.R. Costanzo; Rush Presbyterian St. Luke’s Medical Center, Chicago, IL, USA Background: Previous studies report greater heart failure (HF) mortality in African Americans (AA) compared to Caucasians (C) and women compared to men. We hypothesize that survival is similar regardless of race and gender when treated in a specialized HF program. Methods: We analyzed survival, # of admissions (adm) and use of outpatient (OP) resources by race and gender for 734 cardiomyopathy (CM) patients. Follow-up was from initial visit to death, transplant or ventricular assist device (VAD). Results: Survival was comparable between AA vs. C (mean 1470⫾72 days vs 1521⫾46 days p⫽0.6) and males vs females between and within racial groups. AA had more adm/yr (1.2⫾2.1 vs 0.5⫾1.1 p⬍0.01) with longer length of stay/yr. (10.4⫾25.2days vs 4.4⫾14.3days p⬍0.01). AA required more OP support in the form of inotropes (I) and home nursing (HN) after hospital discharge.(table) Conclusions: Delivery of care in a comprehensive HF program results in similar survival regardless of race or gender despite baseline differences in etiology, initial LVEF, hospitalizations and utilization of OP resourses. Characteristics ischemic CM dilated CM peripartum CM initial LVEF % last LVEF % OP Resources intermittent I continuous I HN/hosp

AA nⴝ203

C nⴝ531

p VALUE

maleⴝ125 ageⴝ45 36 (18%) 140 (69%) 9 (4.4%) 23⫾11 32⫾18

maleⴝ358 ageⴝ57 274 (52%) 199 (37%) 6 (1%) 27⫾12 33⫾14

⬍0.01 ⬍0.01 ⬍0.01 ⬍0.01 NS

21 (10%) 29 (14%) 214/413(52%)

29 (5%) 30 (6%) 164/521(32%)

⬍0.05 ⬍0.01 ⬍0.01