Use of a Highly Sensitive Assay for Cardiac Troponin T as an Adjunct to Diagnose Acute Rejection after Cardiac Transplant

Abstracts S205 QC, Canada; 3Sanofi Canada, Laval, QC, Canada; 4Montreal Health Innovations Coordinating Center, Montreal, QC, Canada. Purpose: New onset diabetes after transplantation (NODAT) promotes cardiovascular diseases. The recent changes in recipients and cardiac donor demography may increase their risk for developing NODAT. The objective of this study was to investigate the secular trends of the risk of NODAT at 1 year and 3 years over a 30 years follow-up in a large cohort of cardiac transplant (CTx) recipients, and to compare the recipient and donor characteristics over that period. Methods: We conducted a retrospective cohort study of 303 non-diabetic patients discharged alive following a first CTx performed in one single transplant center between 1983 and 2011 and followed for a minimum of 24 months (2013). The patients were divided into 3 eras (1983-1992 [Group 1]; 1993-2002 [Group 2] and 2003-2011 [Group 3]). The diagnosis of NODAT was performed based on the initiation of hypoglycemic drug, fasting blood glucose ≥ 7 mmol/ L or HBA1C ≥ 6.5% at least once within 12 months following discharge from CTx and at 3 years post CTx. Results: Patients transplanted in Group 3 were most likely to be females, have non-ischemic heart disease, and most likely to receive inotropic or mechanical support before CTx. The rate of cyclosporine use decreased from 98% to 40% while tacrolimus utilisation increased from 0% to 58% from 1983 to 2011. There was no difference in BMI. Age at transplant tend to increase from 43.3±10.3 (Group 1) to 45.1±13.4 years (Group 3); (p=  0.057), and from 45.1±13.4 (Group 1 and diabetes) vs 50.7±10.7 (Group 3 and diabetes); (p= 0.056). The proportion of patients with NODAT at 1 year was 23%, 21%, and 33% for Groups 1, 2 and 3, respectively (p= 0.15). At 3 years, 39%, 27% and 37% experienced diabetes in Groups 1, 2 and 3, respectively (p= 0.06). Conclusion: The rate of NODAT at 1 year has not changed over 30 years despite slightly older recipients, older donors, and increased use of tacrolimus. Nevertheless, the rate of new onset diabetes remains close to 40% at 3 years justifying aggressive preventive measures early after CTx. 5( 47) Reduction in Post-Heart Transplant ICU and Total Length of Stay by Standardization of Care Via a Multidisciplinary Approach R.K. Cheng ,1 J.D. Pal,2 N.A. Mokadam,2 V. Chaudhari,3 T.F. Dardas,1 K.D. O’Brien,1 J.W. Smith,2 S. Moore,1 W.C. Levy,1 S.C. Masri,1 A. Stempien-Otero,1 C. Mahr,1 D.P. Fishbein.1  1Cardiology, University of Washington, Seattle, WA; 2Cardiac Surgery, University of Washington, Seattle, WA; 3Medicine, University of Washington, Seattle, WA. Purpose: Due to increasing volume of cardiac transplants (Tx) in our program, we sought to standardize post-Tx care, hypothesizing that it would improve post-Tx outcome measures, particularly length-of-stay (LOS). Methods: A multidisciplinary committee was formed to focus on standardizing post-Tx ICU-level care and the hospital-to-outpatient transition process for the index Tx admission. A provider-level post-Tx pathway of care was developed and instituted on 12/31/2014. Post-Tx outcome measures, including ICU and total LOS, mortality, and readmission rates, were compared for the 12 month period prior to and 9 month period following pathway initiation. Results: Tx numbers were 37 (3.1/mo) for the pre-pathway and 30 (3.3/mo) for the post-pathway periods. Despite an increase in case mix index (CMI) from the pre- to post-pathway periods (22.6 ± 4.5 vs. 24.7 ± 2.5, p <  0.01), median (IQR 25-75) ICU LOS decreased from 9.0 (7.0-11.5) to 7.0 (6.09.0) days and median total LOS from 15.0 (12.0-25.0) to 14.5 (10.0-17.3) days. By Poisson regression, the unadjusted post- vs. pre-pathway ICU LOS incidence rate ratio (IRR) was 0.69 (95% CI: 0.57-0.82, p <  0.001), and 0.63 (0.52-0.75, p <  0.001) after adjustment for CMI. Similarly, the unadjusted Poisson IRR for total LOS was 0.75 (0.67-0.85, p <  0.001), and 0.69 (0.610.78, p <  0.001) after adjustment for CMI. The post-pathway cost per case trended $30.3k lower than pre-pathway (p =  0.26). There were no significant pre- vs. post-pathway changes in either in-hospital mortality (pre: 5.4% vs. post: 3.3%, Fisher’s exact p =  1.00) or 30-day re-admission rate (pre: 18.9% vs. post: 30.0%, Fisher’s exact p =  0.39). Conclusion: A multidisciplinary approach to standardization of care may be beneficial in the post-Tx setting. In our program, institution of standardized post-Tx care pathways resulted in reductions in ICU and total LOS, without adverse effects on survival or re-admission.

5( 48) Use of a Highly Sensitive Assay for Cardiac Troponin T as an Adjunct to Diagnose Acute Rejection after Cardiac Transplant U. Boeken ,1 A. Mehdiani,1 C. Ballazs,1 C. Sowa,1 R. Westenfeld,2 D. Saeed,1 P. Akhyari,1 A. Lichtenberg.1  1Cardiovascular Surgery, University Hospital, Duesseldorf, Germany; 2Cardiology, University Hospital, Duesseldorf, Germany. Purpose: As a consequence to cardiomyocyte damage and inflammatory response, it may be possible that highly sensitive cardiac troponin T (hscTnT) and CRP- as well PCT-concentrations may correlate with the histologic degree of rejection in patients after heart transplant (htx). As former results regarding cTnT in this topic are inconsistent, we wanted to evaluate the new hs-cTnT as a potential adjunct to endomyocardial biopsy (EMB) in diagnosis of rejection after htx. Methods: We measured hs-cTnT levels in heart transplant recipients on the first 5 postoperative days and with each biopsy. CRP, PCT and creatinkinase MB were also determined at the same times. The results of EMB were graded according the classification of the International Society of Heart and Lung Transplantation (ISHLT) of 2005. Rejection was defined as an ISHLT grade ≥  2R. Results: Between 10/2010 and 10/2015 56 patients underwent htx in our department. A total of 225 biopsies were performed with a mean followup of 1101 days (range:10-1869 days). We had 10 rejection episodes in which we could measure a moderate elevation of hs-cTnT levels (p= 0.05), whereas CRP increased significantly starting one day before EMB (p< 0.05). However, concentrations of CK-MB and PCT remained constantly low at the same times. TnT-levels decreased to baseline values immediately after successful treatment of rejection. Conclusion: Cardiac TnT measured by the new highly sensitive assay increased in the presence of an acute rejection. In combination with CRP it may be a useful parameter to support the posttransplant management with regard to clinical and histological suspicion of rejection. 5( 49) Outcomes in Patients Older than 65 Years of Age Post Heart (HT) & Heart-Kidney Transplant (HKT) A. Iyengar , C. Eisenring, A. Nsair, M. Deng, L. Reardon, A. Ardehali, E. DePasquale.  University of California - Los Angeles, Los Angeles, CA. Purpose: Outcomes in older recipients following heart-kidney transplant (HKT) has not been well described. With limited donor availability, we sought to evaluate the outcomes of HKT in an older patient population. Methods: 4408 recipients (exclusions included age< 18) were identified from UNOS (1987-2014) & stratified by transplant type (HT & HKT) who were ≥  65y. Survival was censored at 12y. Multivariate Cox proportional hazard regression analysis was adjusted for age, sex, DM, race, ischemic time, dialysis, life support, wait time & HLA mismatch. Results: There were 88 HKT and 4320 HT (9.9%) ≥ 65y, of which 634 (HKT: n= 8) were ≥  70y. Ischemic & dilated cardiomyopathy were prevalent in both groups, with restrictive cardiomyopathy more prevalent in the HKT pts (7% vs 2%, p= 0.013). The HKT group was less likely to be female (p= 0.045), more likely to have diabetes (47% vs 27%, p <  0.001) and require dialysis (24% vs 1%, p <  0.001). Survival (1, 5, 10y) was: HT (85, 70, 46%) & HKT (80, 70, 53%) (Figure, p =  NS). Unadjusted HR for all-cause mortality was 1.02 (CI 0.69-1.52). Multivariate analysis yielded a HR 0.92 (CI 0.60-1.40). Conclusion: In selected patients, HKT can be performed with comparable outcomes to heart-only transplantation in adults ≥  65y. Offering HKT to selected patients is warranted. Further study is needed to improve patient selection for HKT.