- Email: [email protected]
Utility of Routine versus Triggered Evaluations of Rejection Greater Than Two Years Following Heart Transplant
Abstracts
S211
binding level ≥40 U/ml developed moderate-severe PGD (see table) but this did not reach statistical significance. Conclusion: Despite reported risk of poor outcome in MCS pts with AT1R Abs, the presence of these Abs do not appear to confer increased risk in post-heart transplant outcomes from these MCS pts. Of particular note, higher AT1R antibody levels did not appear to be associated with increased PGD risk.
MCS + AT1R (n=76)
Endpoints Incidence of ModerateSevere PGD, % 1-Year Survival 1-Year Freedom from CAV 1-Freedom from NF-MACE 1-Freedom from Any-Treated Rejection 1-Year Freedom from Acute Cellular Rejection 1-Year Freedom from Antibody-Mediated Rejection
Binding Level <40 U/ml (n=24)
Binding Level ≥ 40 U/ml (n=52)
MCS w/o AT1R (n=92)
P-Value
0.0% (0/24)
7.8% (4/52)
6.5% (6/92)
0.396
90.5% 89.7% 87.0% 94.4%
90.2% 93.8% 91.9% 85.5%
92.8% 94.1% 84.0% 81.4%
0.780 0.858 0.432 0.344
100.0%
98.0%
95.2%
0.492
100.0%
91.5%
94.3%
0.387
503 Predictors and Clinical Outcomes of Vasoplegia in Patients Bridged to Heart Transplantation with Continuous Flow Left Ventricular Assist Devices R. Asleh, H. Alnsasra, S.D. Schettle, R. Taher, S.M. Dunlay, J.M. Stulak, R. C. Daly, A. Behfar, N.L. Pereira, A.L. Clavell, S. Multais, R.P. Frantz and S.S. Kushwaha. Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN. Purpose: Vasoplegia has been implicated in adverse outcomes after heart transplantation (HT). Although left ventricular assist device (LVAD) is associated with increased risk of vasoplegia, pre-operative predictors of vasoplegia in this population and its impact on survival after HT are unknown. In this study, we sought to examine predictors and outcomes of patients who develop vasoplegia after HT following bridging therapy with continuous flow LVAD. Methods: We retrospectively analyzed 94 patients who underwent HT after bridging with LVAD between July, 2008 and June, 2018 at a large institution. Vasoplegia was defined as persistent low vascular resistance requiring ≥2 intravenous vasopressors within 48 hours post HT for >24 hours to maintain a mean arterial pressure >70 mm Hg. Logistic regression was used to examine predictors of vasoplegia and the association with survival was examined using Cox proportional hazard regression. Results: Overall, 44 (46.8%) patients with LVAD developed vasoplegia after HT. Patients with and without vasoplegia had similar pre-operative LVAD, echocardiographic, and hemodynamic parameters. Patients with vasoplegia were significantly older, had longer LVAD support, higher preoperative creatinine, cardiopulmonary bypass time (CBT), and Charlson comorbidity index, and had higher rates of hypothyroidism and sustained ventricular tachycardia (VT) (all p<0.05). In a multivariate logistic regression, longer LVAD support (odds ratio [OR] 1.05 per 1 month increase; p= 0.029), pre-HT creatinine (OR 6.5 per 1 mg/dl increase; p=0.011), CBT (OR 1.01 per 1 minute increase; p=0.034), and sustained VT (OR 3.08; p=0.031) were significant predictors of vasoplegia. After a mean follow-up of 4.0 years post HT, vasoplegia was associated with increased risk of allcause mortality (hazard ratio [HR] 5.20, 95% confidence interval [CI] 1.71-19.28; p<0.01). Conclusion: Longer LVAD support, impaired renal function, sustained VT, and prolonged intra-operative CBT are independent predictors of vasoplegia in patients undergoing HT after LVAD bridging. Vasoplegia is associated with poor prognosis; hence, detailed assessment of these predictors can be clinically important.
504 Elevated Pre-Transplant Neutrophil to Lymphocyte Ratio is Associated with Increased Vasoplegia Syndrome in Cardiac Transplantation N. Ahmed, H. Gandhi, K. Rahgozar, S. Guo, E. Sun, O. Saeed, S. Patel, S. Murthy, J.J. Shin, S. Vukelic, S. Forest, D.J. Goldstein, U.P. Jorde and D.B. Sims. Montefiore Medical Center Albert Einstein College of Medicine, Bronx, NY. Purpose: Neutrophil to lymphocyte ratio (NLR), calculated from a CBC, is a marker of systemic inflammation and long-term risk in chronic illness, including heart failure (HF). Vasoplegia syndrome is a severe vasodilatory shock state after cardiac surgery. Patients undergoing heart transplantation (HTx) may be at an increased risk of vasoplegia due to inflammatory cytokine release secondary to HF. The role of NLR as a predictive marker for vasoplegia in patients undergoing HTx has not been studied. Methods: Retrospective review of consecutive patients who underwent HTx from 7/2016 to 7/2018. Patients with conditions or treatments known to affect WBC count were excluded. Pre-HTx NLR was calculated from day of HTx and stratified by tertile. Vasoplegia was defined as vasopressor administration for > 24 hours to maintain mean arterial pressure > 65 mmHg for hypotension not attributed to other etiologies within 48 hours of HTx. The primary outcome was rates of vasoplegia between tertiles. Results: 78 patients underwent HTx of which 70 met inclusion criteria. 18 patients had vasoplegia. Vasoplegia occurred in 8.7% (n=2) in the 1st tertile, 25% (n=6) in the 2nd tertile and 43.4% (n= 10) in the 3rd tertile (comparison 1st vs 3rd tertile, p=0.04) (Figure). In a multivariate analysis, adjusted for prior LVAD, patients in the 3rd tertile had higher rates of vasoplegia (adjusted OR 2.47, 95% CI 1.87-4.55) compared to the 1st. Mean NLR in patients without vasoplegia was 3.68§0.48 compared to 6.72§1.7 in patients with vasoplegia (p=0.019). There was no demographic or medical comorbidity difference other than hypothyroidism (p=0.04) between groups. Conclusion: Vasoplegia is associated with elevated pre-HTx NLR compared to patients without vasoplegia. Chronic inflammation due to HF may play a role in the development of post-HTx vasoplegia. NLR is an inexpensive tool which clinicians may use pre-HTx to stratify which patients are at an increased risk of development of vasoplegia post-HTx.
505 Utility of Routine versus Triggered Evaluations of Rejection Greater Than Two Years Following Heart Transplant J.R. Golbus, M.C. Konerman and K.D. Aaronson. Internal Medicine, University of Michigan, Ann Arbor, MI. Purpose: Routine surveillance endomyocardial biopsies (EMBx) are recommended for 6-12 months after orthotopic heart transplantation (OHT) though may be replaced by gene expression profiling (Allomap) in lowrisk patients after 6-months. There are limited data on the utility of routine studies after the second post-transplant year.
S212
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
Methods: We retrospectively identified adult patients who underwent OHT from 2007-2015 and who survived ≥760 days post-OHT. Clinical characteristics and outcomes were obtained on chart review. All Allomaps and EMBx during years 2-5 were extracted from the medical record, and their clinical context reviewed to determine if they were performed routinely or were triggered by a change in clinical status defined by symptoms, imaging, or biomarkers. Significant rejection was defined as ≥2R acute cellular rejection (ACR), any antibody-mediated rejection (AMR), or treated biopsy-negative rejection. Studies within one year of a significant rejection episode were considered triggered. Patients were categorized based on whether the treating cardiologist intended to continue routine studies after the second post-OHT year. Logistic regression was used to evaluate factors predictive of surveillance strategy. Results: 217 patients met the above criteria, totaling 1,368 patient-years. 1020 studies were performed after day 760 of which 835 (81.9%) were routine (201 EMBx, 634 Allomaps). Of the routine EMbx, two (1%) demonstrated rejection—one 2R ACR and one pAMR2; both patients had BNP elevations. The remaining studies were negative for significant rejection. Routinely ordered Allomaps triggered 36 EMBx (5.7%), of which 1 (0.2%) demonstrated rejection requiring treatment. 53 patients followed a “no routine surveillance” strategy and 159 a “routine surveillance” strategy. There were no differences in heart failure hospitalization, revascularization, or death between the groups. On multivariable logistic regression, treating cardiologist was the only predictor of surveillance strategy (p<0.0001). Conclusion: Although acute rejection is rare after the second post-OHT year, routine studies were performed commonly at our institution. Treating cardiologist but not clinical risk factors predicted choice of surveillance strategy. These data do not justify routine evaluations for rejection after two years.
506 Protocol Endomyocardial Biopsy beyond Six Months - It’s Time to Move On K. Oh,1 M.H. Mustehsan,1 D.B. Sims,1 O. Saeed,1 S. Vukelic,1 J.J. Shin,1 S. Murthy,1 A. Luke,1 S.J. Forest,2 D. Goldstein,2 U. Jorde,1 and S. R. Patel.1 1Medicine, Division of Cardiology, Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY; and the 2Cardiovascular and Thoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY. Purpose: Despite the low incidence of cardiac allograft rejection beyond 6 months after heart transplant (HTX), surveillance endomyocardial biopsy (EMB) is commonly performed up-to 1 year and beyond. We aim to investigate the value of routine EMB beyond 6 months. Methods: A single center retrospective review was conducted on all adult HTX recipients between 2008 and 2017. Patients who did not complete routine EMB beyond 6 months post-HTX were excluded. EMB results were reviewed for rejections, defined as ISHLT grade ≥ 2R or >pAMR1. Each rejection was then reviewed to determine if it was diagnosed on protocol (at 1, 2, 3, 4, 6, 8, 10, 12, 16, 20, 24, 32, 40, and 52 weeks) or symptom-triggered EMB. Results: A total of 2714 EMBs were performed in 198 HTX recipients, characterized by median age 55 (47-63 years), 30% female, 28% African American, 65% with pre-HTX LVAD, and 30% with PRA>30% (MFI > 1000). The incidence of rejection was significantly higher during the first 6 months post-HTX (Figure 1A). Thirty-two out of 1960 EMBs from the first 6 months had rejection (1.62%), compared to 5 rejections in 755 EMBs between 6-12 months post-HTX (0.66%, p=0.05). These rejections occurred in 27 vs. 5 out of 198 patients (13.6% vs. 2.53%, p<0.0001). Importantly, protocol EMB identified the majority of rejections during the first 6 months (92.6%), but only 1 of the rejections after 6 months (p=0.002, Figure 1B). Of note, this single rejection was grade 3R, but without hemodynamic compromise or graft dysfunction, in the setting of reduced immunosuppression due to leukopenia. Conclusion: EMB was found to be a low-yield screening modality for rejection beyond 6 months post-HTX. The need for protocol EMB beyond 6 months warrants further investigation.
507 Clinical Utility of the IMPACT Score for Mortality Prediction after Heart Transplantation: External Validation Study C.D. Ortiz Bautista,1 J. Muniz Garcia,2 F. Gonzalez-Vilchez,3 J. Segovia Cubero,4 M.G. Crespo Leiro,5 R. Lopez Vilella,6 J. Gonzalez Costelo,7 E. Roig Minguel,8 J.M. Arizon Del Prado,9 J.M. Sobrino Marquez,10 I.P. Garrido Bravo,11 and J.F. Delgado Jimenez.12 1Cardiology, Hospital General Universitario Gregorio Mara~non, Madrid, Spain; 2Instituto de Investigacion Biomedica (INIBIC), Complexo Hospitalario Universitario de A Coru~na, A Coru~na, Spain; 3Cardiology, Hospital Universitario Marques de Valdecilla, Santander, Spain; 4Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain; 5Cardiology, Complexo Hospitalario Universitario de A Coru~na, A Coru~na, Spain; 6Cardiology, Hospital Universitario La Fe, Valencia, Spain; 7Cardiology, Hospital Universitario de Bellvitge, Barcelona, Spain; 8Cardiology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; 9Cardiology, Hospital Universitario Reina Sofía, Cordoba, Spain; 10Cardiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain; 11Cardiology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain; and the 12Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain. Purpose: The primary objective of this work is to externally validate the Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score in the Spanish cohort. Methods: Spanish Heart Transplant Registry data were used to identify isolated adult (>16 years) OHT performed from 2000 to 2015. Individual values of the IMPACT score were calculated for each patient. Overall 1year mortality after OHT was assessed and 1-year mortality rates between predefined IMPACT score groups (0-2pts, 3-5pts, 6-9ptos, 10-14ptos, ≥15pts) were compared. Correlation between the observed and expected mortality according to the IMPACT score was evaluated. Finally, discrimination ability was assessed by the area under the ROC curve. Results: We identified 2,814 OHT. Baseline characteristics are shown in the table. Mean value of the IMPACT score was 6.3§4.9 points. Overall 1-year survival rate was 79.1%. Kaplan-Meier 1-year survival rates by IMPACT score groups were 84.6%, 81.3%, 79.4%, 76.4% and 58.3% respectively (p <0.001). Correlation between the observed mortality in our series and that expected according to the IMPACT score was good (r=0.78), while its discrimination ability was poor (AUC=0.52). Conclusion: OHT mortality in Spain is adjusted to that expected by the IMPACT score, so there is good calibration of the predictive model. However, its predictive strength is poor and similar to that determined by chance. On the other hand, there is a lack of studies that evaluate the impact on clinical practice and outcomes of OHT. In the absence of these studies, we cannot implement the IMPACT score in our daily clinical decision making.
Baseline characteristics. 1Includes: ECMO, Abiomed BVS 5000, Levitronix, BioMedicus e Impella CP. Age (years), mean § SD Race -Caucasian, n (%) -Black, n (%) Serum Bilirrubin (mg/dl), mean § SD
N=2,814 53 § 12 2802 (99,6) 12 (0,4) 1,3 § 1,1 (continued)
S211
binding level ≥40 U/ml developed moderate-severe PGD (see table) but this did not reach statistical significance. Conclusion: Despite reported risk of poor outcome in MCS pts with AT1R Abs, the presence of these Abs do not appear to confer increased risk in post-heart transplant outcomes from these MCS pts. Of particular note, higher AT1R antibody levels did not appear to be associated with increased PGD risk.
MCS + AT1R (n=76)
Endpoints Incidence of ModerateSevere PGD, % 1-Year Survival 1-Year Freedom from CAV 1-Freedom from NF-MACE 1-Freedom from Any-Treated Rejection 1-Year Freedom from Acute Cellular Rejection 1-Year Freedom from Antibody-Mediated Rejection
Binding Level <40 U/ml (n=24)
Binding Level ≥ 40 U/ml (n=52)
MCS w/o AT1R (n=92)
P-Value
0.0% (0/24)
7.8% (4/52)
6.5% (6/92)
0.396
90.5% 89.7% 87.0% 94.4%
90.2% 93.8% 91.9% 85.5%
92.8% 94.1% 84.0% 81.4%
0.780 0.858 0.432 0.344
100.0%
98.0%
95.2%
0.492
100.0%
91.5%
94.3%
0.387
503 Predictors and Clinical Outcomes of Vasoplegia in Patients Bridged to Heart Transplantation with Continuous Flow Left Ventricular Assist Devices R. Asleh, H. Alnsasra, S.D. Schettle, R. Taher, S.M. Dunlay, J.M. Stulak, R. C. Daly, A. Behfar, N.L. Pereira, A.L. Clavell, S. Multais, R.P. Frantz and S.S. Kushwaha. Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN. Purpose: Vasoplegia has been implicated in adverse outcomes after heart transplantation (HT). Although left ventricular assist device (LVAD) is associated with increased risk of vasoplegia, pre-operative predictors of vasoplegia in this population and its impact on survival after HT are unknown. In this study, we sought to examine predictors and outcomes of patients who develop vasoplegia after HT following bridging therapy with continuous flow LVAD. Methods: We retrospectively analyzed 94 patients who underwent HT after bridging with LVAD between July, 2008 and June, 2018 at a large institution. Vasoplegia was defined as persistent low vascular resistance requiring ≥2 intravenous vasopressors within 48 hours post HT for >24 hours to maintain a mean arterial pressure >70 mm Hg. Logistic regression was used to examine predictors of vasoplegia and the association with survival was examined using Cox proportional hazard regression. Results: Overall, 44 (46.8%) patients with LVAD developed vasoplegia after HT. Patients with and without vasoplegia had similar pre-operative LVAD, echocardiographic, and hemodynamic parameters. Patients with vasoplegia were significantly older, had longer LVAD support, higher preoperative creatinine, cardiopulmonary bypass time (CBT), and Charlson comorbidity index, and had higher rates of hypothyroidism and sustained ventricular tachycardia (VT) (all p<0.05). In a multivariate logistic regression, longer LVAD support (odds ratio [OR] 1.05 per 1 month increase; p= 0.029), pre-HT creatinine (OR 6.5 per 1 mg/dl increase; p=0.011), CBT (OR 1.01 per 1 minute increase; p=0.034), and sustained VT (OR 3.08; p=0.031) were significant predictors of vasoplegia. After a mean follow-up of 4.0 years post HT, vasoplegia was associated with increased risk of allcause mortality (hazard ratio [HR] 5.20, 95% confidence interval [CI] 1.71-19.28; p<0.01). Conclusion: Longer LVAD support, impaired renal function, sustained VT, and prolonged intra-operative CBT are independent predictors of vasoplegia in patients undergoing HT after LVAD bridging. Vasoplegia is associated with poor prognosis; hence, detailed assessment of these predictors can be clinically important.
504 Elevated Pre-Transplant Neutrophil to Lymphocyte Ratio is Associated with Increased Vasoplegia Syndrome in Cardiac Transplantation N. Ahmed, H. Gandhi, K. Rahgozar, S. Guo, E. Sun, O. Saeed, S. Patel, S. Murthy, J.J. Shin, S. Vukelic, S. Forest, D.J. Goldstein, U.P. Jorde and D.B. Sims. Montefiore Medical Center Albert Einstein College of Medicine, Bronx, NY. Purpose: Neutrophil to lymphocyte ratio (NLR), calculated from a CBC, is a marker of systemic inflammation and long-term risk in chronic illness, including heart failure (HF). Vasoplegia syndrome is a severe vasodilatory shock state after cardiac surgery. Patients undergoing heart transplantation (HTx) may be at an increased risk of vasoplegia due to inflammatory cytokine release secondary to HF. The role of NLR as a predictive marker for vasoplegia in patients undergoing HTx has not been studied. Methods: Retrospective review of consecutive patients who underwent HTx from 7/2016 to 7/2018. Patients with conditions or treatments known to affect WBC count were excluded. Pre-HTx NLR was calculated from day of HTx and stratified by tertile. Vasoplegia was defined as vasopressor administration for > 24 hours to maintain mean arterial pressure > 65 mmHg for hypotension not attributed to other etiologies within 48 hours of HTx. The primary outcome was rates of vasoplegia between tertiles. Results: 78 patients underwent HTx of which 70 met inclusion criteria. 18 patients had vasoplegia. Vasoplegia occurred in 8.7% (n=2) in the 1st tertile, 25% (n=6) in the 2nd tertile and 43.4% (n= 10) in the 3rd tertile (comparison 1st vs 3rd tertile, p=0.04) (Figure). In a multivariate analysis, adjusted for prior LVAD, patients in the 3rd tertile had higher rates of vasoplegia (adjusted OR 2.47, 95% CI 1.87-4.55) compared to the 1st. Mean NLR in patients without vasoplegia was 3.68§0.48 compared to 6.72§1.7 in patients with vasoplegia (p=0.019). There was no demographic or medical comorbidity difference other than hypothyroidism (p=0.04) between groups. Conclusion: Vasoplegia is associated with elevated pre-HTx NLR compared to patients without vasoplegia. Chronic inflammation due to HF may play a role in the development of post-HTx vasoplegia. NLR is an inexpensive tool which clinicians may use pre-HTx to stratify which patients are at an increased risk of development of vasoplegia post-HTx.
505 Utility of Routine versus Triggered Evaluations of Rejection Greater Than Two Years Following Heart Transplant J.R. Golbus, M.C. Konerman and K.D. Aaronson. Internal Medicine, University of Michigan, Ann Arbor, MI. Purpose: Routine surveillance endomyocardial biopsies (EMBx) are recommended for 6-12 months after orthotopic heart transplantation (OHT) though may be replaced by gene expression profiling (Allomap) in lowrisk patients after 6-months. There are limited data on the utility of routine studies after the second post-transplant year.
S212
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
Methods: We retrospectively identified adult patients who underwent OHT from 2007-2015 and who survived ≥760 days post-OHT. Clinical characteristics and outcomes were obtained on chart review. All Allomaps and EMBx during years 2-5 were extracted from the medical record, and their clinical context reviewed to determine if they were performed routinely or were triggered by a change in clinical status defined by symptoms, imaging, or biomarkers. Significant rejection was defined as ≥2R acute cellular rejection (ACR), any antibody-mediated rejection (AMR), or treated biopsy-negative rejection. Studies within one year of a significant rejection episode were considered triggered. Patients were categorized based on whether the treating cardiologist intended to continue routine studies after the second post-OHT year. Logistic regression was used to evaluate factors predictive of surveillance strategy. Results: 217 patients met the above criteria, totaling 1,368 patient-years. 1020 studies were performed after day 760 of which 835 (81.9%) were routine (201 EMBx, 634 Allomaps). Of the routine EMbx, two (1%) demonstrated rejection—one 2R ACR and one pAMR2; both patients had BNP elevations. The remaining studies were negative for significant rejection. Routinely ordered Allomaps triggered 36 EMBx (5.7%), of which 1 (0.2%) demonstrated rejection requiring treatment. 53 patients followed a “no routine surveillance” strategy and 159 a “routine surveillance” strategy. There were no differences in heart failure hospitalization, revascularization, or death between the groups. On multivariable logistic regression, treating cardiologist was the only predictor of surveillance strategy (p<0.0001). Conclusion: Although acute rejection is rare after the second post-OHT year, routine studies were performed commonly at our institution. Treating cardiologist but not clinical risk factors predicted choice of surveillance strategy. These data do not justify routine evaluations for rejection after two years.
506 Protocol Endomyocardial Biopsy beyond Six Months - It’s Time to Move On K. Oh,1 M.H. Mustehsan,1 D.B. Sims,1 O. Saeed,1 S. Vukelic,1 J.J. Shin,1 S. Murthy,1 A. Luke,1 S.J. Forest,2 D. Goldstein,2 U. Jorde,1 and S. R. Patel.1 1Medicine, Division of Cardiology, Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY; and the 2Cardiovascular and Thoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY. Purpose: Despite the low incidence of cardiac allograft rejection beyond 6 months after heart transplant (HTX), surveillance endomyocardial biopsy (EMB) is commonly performed up-to 1 year and beyond. We aim to investigate the value of routine EMB beyond 6 months. Methods: A single center retrospective review was conducted on all adult HTX recipients between 2008 and 2017. Patients who did not complete routine EMB beyond 6 months post-HTX were excluded. EMB results were reviewed for rejections, defined as ISHLT grade ≥ 2R or >pAMR1. Each rejection was then reviewed to determine if it was diagnosed on protocol (at 1, 2, 3, 4, 6, 8, 10, 12, 16, 20, 24, 32, 40, and 52 weeks) or symptom-triggered EMB. Results: A total of 2714 EMBs were performed in 198 HTX recipients, characterized by median age 55 (47-63 years), 30% female, 28% African American, 65% with pre-HTX LVAD, and 30% with PRA>30% (MFI > 1000). The incidence of rejection was significantly higher during the first 6 months post-HTX (Figure 1A). Thirty-two out of 1960 EMBs from the first 6 months had rejection (1.62%), compared to 5 rejections in 755 EMBs between 6-12 months post-HTX (0.66%, p=0.05). These rejections occurred in 27 vs. 5 out of 198 patients (13.6% vs. 2.53%, p<0.0001). Importantly, protocol EMB identified the majority of rejections during the first 6 months (92.6%), but only 1 of the rejections after 6 months (p=0.002, Figure 1B). Of note, this single rejection was grade 3R, but without hemodynamic compromise or graft dysfunction, in the setting of reduced immunosuppression due to leukopenia. Conclusion: EMB was found to be a low-yield screening modality for rejection beyond 6 months post-HTX. The need for protocol EMB beyond 6 months warrants further investigation.
507 Clinical Utility of the IMPACT Score for Mortality Prediction after Heart Transplantation: External Validation Study C.D. Ortiz Bautista,1 J. Muniz Garcia,2 F. Gonzalez-Vilchez,3 J. Segovia Cubero,4 M.G. Crespo Leiro,5 R. Lopez Vilella,6 J. Gonzalez Costelo,7 E. Roig Minguel,8 J.M. Arizon Del Prado,9 J.M. Sobrino Marquez,10 I.P. Garrido Bravo,11 and J.F. Delgado Jimenez.12 1Cardiology, Hospital General Universitario Gregorio Mara~non, Madrid, Spain; 2Instituto de Investigacion Biomedica (INIBIC), Complexo Hospitalario Universitario de A Coru~na, A Coru~na, Spain; 3Cardiology, Hospital Universitario Marques de Valdecilla, Santander, Spain; 4Cardiology, Hospital Universitario Puerta de Hierro, Madrid, Spain; 5Cardiology, Complexo Hospitalario Universitario de A Coru~na, A Coru~na, Spain; 6Cardiology, Hospital Universitario La Fe, Valencia, Spain; 7Cardiology, Hospital Universitario de Bellvitge, Barcelona, Spain; 8Cardiology, Hospital Santa Creu i Sant Pau, Barcelona, Spain; 9Cardiology, Hospital Universitario Reina Sofía, Cordoba, Spain; 10Cardiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain; 11Cardiology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain; and the 12Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain. Purpose: The primary objective of this work is to externally validate the Index for Mortality Prediction After Cardiac Transplantation (IMPACT) score in the Spanish cohort. Methods: Spanish Heart Transplant Registry data were used to identify isolated adult (>16 years) OHT performed from 2000 to 2015. Individual values of the IMPACT score were calculated for each patient. Overall 1year mortality after OHT was assessed and 1-year mortality rates between predefined IMPACT score groups (0-2pts, 3-5pts, 6-9ptos, 10-14ptos, ≥15pts) were compared. Correlation between the observed and expected mortality according to the IMPACT score was evaluated. Finally, discrimination ability was assessed by the area under the ROC curve. Results: We identified 2,814 OHT. Baseline characteristics are shown in the table. Mean value of the IMPACT score was 6.3§4.9 points. Overall 1-year survival rate was 79.1%. Kaplan-Meier 1-year survival rates by IMPACT score groups were 84.6%, 81.3%, 79.4%, 76.4% and 58.3% respectively (p <0.001). Correlation between the observed mortality in our series and that expected according to the IMPACT score was good (r=0.78), while its discrimination ability was poor (AUC=0.52). Conclusion: OHT mortality in Spain is adjusted to that expected by the IMPACT score, so there is good calibration of the predictive model. However, its predictive strength is poor and similar to that determined by chance. On the other hand, there is a lack of studies that evaluate the impact on clinical practice and outcomes of OHT. In the absence of these studies, we cannot implement the IMPACT score in our daily clinical decision making.
Baseline characteristics. 1Includes: ECMO, Abiomed BVS 5000, Levitronix, BioMedicus e Impella CP. Age (years), mean § SD Race -Caucasian, n (%) -Black, n (%) Serum Bilirrubin (mg/dl), mean § SD
N=2,814 53 § 12 2802 (99,6) 12 (0,4) 1,3 § 1,1 (continued)