Conclusions: ECMO for circulatory support significantly improved heart/brain oxygen ... 554 days (range 365 â 1373 days). The primary diagnosis was ... (8%) had a device failure report but only for two patients it was the leading cause of death ...
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The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2013
Conclusions: ECMO for circulatory support significantly improved heart/brain oxygen supply to the patient with compromised lung function, promoting injured heart recovery. 300 Long Term Results with Total Artificial Heart: Is It Prime Time for Destination Therapy? G. Torregrossa,1 G. Gerosa,1 V. Tarzia,1 V. Vida,1 D. Duveau,2 F. Arabia,3 P. Leprince,4 V. Kasirajan,5 F. Beyersdof,6 A. Loforte,7 F. Musumeci,7 R. Hetzer,8 T. Krabatsch,8 J. Gummert,9 M. Morshuis,9 J. Copeland.1 1Cardiac Surgery, University of Padua, Padua, Italy; 2 Department of Thoracic and Cardiovascular Surgery, Institut du Thorax, Nantes, France; 3Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ; 4Service de Chirurgie Thoracique et Cardiovasculaire, Universite Pierre et Marie Paris, France; 5Division of Cardiothoracic Curie - Hospital LaPitie, Surgery, Virginia Commonwealth University Health System, Richmond, VA; 6Department of Cardiovascular Surgery, University Hospital Medical Center, Freiburg, Germany; 7Department of Cardiology and Cardiovascular Surgery, Azienda Ospedaliera S. Camillo-Forlanini, Rome, Italy; 8Deutsches Herzzentrum Berlin, Berlin, Germany; 9 Herz- und Diabeteszentrum NRW, Universitatsklinikum der Ruhr¨ Universitat ¨ Bochum, Bad Oeynhausen, Germany; 10Cardiothoracic Unit Department of Surgery, University Medical Center, Tucson. Purpose: During recent years, mechanical circulatory support (MCS) devices have been increasingly used for long-term support. The Syncardia/CardioWest total artificial heart (TAH) has been implanted in over 1075 patients worldwide as a bridge to transplant. We reviewed data of patients supported more than one year to assess its safety and feasibility as destination therapy device. Methods and Materials: 47 patients from 10 centers worldwide have been included in this retrospective study. Clinical data have been collected on survival, infections, thromboembolic and hemorrhagic events, device failure, antithrombotic therapy regimen and outcome. Results: The median age was 49 years old, the median support time was 554 days (range 365 – 1373 days). The primary diagnosis was dilatative cardiomiopathy in 23 pts, Ischemic in 15 and other in 9. After at least one year of support patients have been successfully transplanted in 72% of cases, 24% died on device and 4 % are still supported. 4 patients (8%) had a device failure report but only for two patients it was the leading cause of death. Major complications were as follows: sistemic infections (19%; 3% leading death), drive line infections (20%, 0% leading death), ischemic (15%, 6% leading death) and hemorrhagic (23%, 6% leading death) events. Moreover antithrombotic regimen, hospital discharge, post operative rehabilitation period, drugs therapy and follow up management have been carefully investigated among our population of patience. Conclusions: Cardiowest (t-TAH) has shown to be a reliable and effective device in replacing the entire heart. Device failure occurred rarely and only in two cases was the leading cause of death. The Syncardia TAH has emerged as a robust form of mechanical circulatory support for biventricular failure patients even in a setting of long term support. The dilemma of destination therapy is more ethical issue up to now considering the major impact in the quality of life of these patients. 301 Longitudinal Investigation of the Effect of Centrifugal Continuous Flow LVADS on Blood Haemostatic Parameters K. Muthiah,1,2,4 D. Connor,2,3 K. Ly,2,3 D. Rutgers,1 D. Robson,1 P.S. Macdonald,1,2,4 K. Dhital,1,2 P. Jansz,1 J. Joseph,2,3 C.S. Hayward.1,2,4 1Heart Failure and Transplant Unit, St. Vincent’s Hospital, Sydney, Australia; 2University of New South Wales, Sydney, Australia; 3Department of Haematology, St. Vincent’s Hospital, Sydney, Australia; 4Victor Chang Cardiac Research Institute, Sydney, Australia. Purpose: Bleeding and thromboembolism impact morbidity and mortality in cfLVAD patients. The effect of cfLVADS on blood haemostatic parameters is analysed in a longitudinal prospective study using novel markers in patients on antiplatelet and anticoagulation.
Methods and Materials: Twenty-five patients (22M,3F; mean age 47⫾12yrs) implanted with the HeartWare HVAD were studied. All patients were on dual antiplatelet therapy and warfarin by D7 post implant. Blood was collected prior to implant and at days 1, 7, 30, 90, 180 post implant. Platelet activation (sPselectin, soluble GPVI), platelet function (multiplate), von Willebrand Factor studies, coagulation profile and platelet microparticles studies were performed at each time point. Results: sP-selectin levels peaked at D1 post implant (52.5⫾38 ng/ ml) with values approximating baseline at all other time points. sGPVI were elevated pre-implant through to D180 (447ng/ml). vWF Collagen binding activity (CBA), CBA:Ag ratio were significantly lower from D30 through D180 from baseline, po0.01. Platelet counts were highest at D30, po0.01, but had highest inhibition with aspirin (Multiplate ASPI) at that time-point, po0.05 (Figure). There was no significant difference in platelet microparticles (ANOVA). Seven patients had clinical bleeding events of whom six patients had events within 180 days post implant. There was no significant difference in results at D90 and D180 in bleeders vs non-bleeders.
Conclusions: cfLVAD use is associated with changes in both markers of procoagulation and anticoagulation with an increased tendency to clinical bleeding events. These changes through time can be used to guide antiplatelet and anticoagulation use. 302 Continuous-Flow Left Ventricular Assist Device Versus Heart Transplantation: A European Perspective E. Ammirati, F.G. Oliva, T. Colombo, C.F. Russo, M. Cipriani, A. Garascia, A. Verde, F. Macera, R. Paino, L. Martinelli, M. Frigerio. Cardiothoracic and Vascular Department, Niguarda Ca’ Granda Hospital, Milan, Italy. Purpose: Left ventricular assist devices (LVAD) are less utilized in Europe than in the United States, especially in Italy, despite donor shortage and use of older donors that limit the availability and the probability of success of heart transplantation (HTx). The aim of this study is to compare one-year survival rates in consecutive patients treated with continuous-flow LVAD versus HTx in the center with the largest national experience in LVAD therapy. Methods and Materials: Preoperative characteristics and one-year survival rates were compared between patients who received a continuous-flow LVAD (n¼49) and those who received HTx (n¼164) at our hospital from 1/2006 to 2/2012. Patients undergoing HTx after LVAD were considered only in LVAD group, with follow up ending at the date of HTx. Results: LVAD patients were more compromised than HTx patients (older age, higher mean pulmonary artery and capillary wedge pressure, larger preoperative use of intra-aortic balloon pump at the time of operation). Average follow up was 12 months (interquartile range 6 to 12 months). A total of 41 deaths occurred: 12 among LVAD patients and 29 among HTx patients. Kaplan Meier survival
Abstracts curves estimated a one-year survival of 75.5% in LVAD vs. 82.3% in HTx patients, which was a non-significant difference (hazard ratio 1.50; 95% confidence interval 0.77-2.94; p¼0.24 for LVAD vs. HTx). Peri-operative mortality at 30 days was 16.3% vs. 11.0%, p¼0.32 in LVAD vs. HTx. LVAD treatment required longer in-hospital stay and an increased number of re-hospitalizations; nevertheless major complications were relatively rare. Transplantation rate at one-year was 8% in our series receiving LVAD therapy. Conclusions: Despite worse preoperative conditions and low transplantation rate, one-year survival is not significantly lower after LVAD than after HTx. Since LVAD is becoming a reliable alternative to HTx at least at medium term, use of LVAD as bridge-totransplantation should be harmonized between centres sharing the same donor pool. 303 The Characteristics and Outcomes of Advanced Heart Failure Patients with Hemodynamic Parameters Predictive of Right Ventricular Failure R.J. Mentz, M.A. Daneshmand, A.D. DeVore, C.A. Milano, J.G. Rogers, C.B. Patel. Duke University Medical Center, Durham, NC. Purpose: Advanced heart failure (HF) patients (pts) with a high central venous pressure (CVP)/pulmonary capillary wedge pressure (PCWP) ratio are at risk for right ventricular failure (RVF) after left ventricular assist device (LVAD) placement. The incidence of this RVF predictor in ambulatory pts with advanced HF and the associated outcomes are unknown. We investigated the ‘‘RVF biomarker’’ of CVP/PCWPZ 0.63 in ambulatory HF pts. Methods and Materials: We analyzed 188 consecutive INTERMACS 4-5 pts evaluated in the Duke HF Clinic (2005-2010) who had a right heart catheterization and cardiopulmonary exercise test (CPX) within 90-days. Pts were stratified by CVP/PCWP Z or o0.63. Pt characteristics, Seattle HF Model (SHFM) score and outcomes (survival free of LVAD/transplant/death) were evaluated. Results: 51 pts (27%) had a ratio Z0.63. The groups were similar with respect to race, gender, HF etiology, and HF medications (all P40.05). Diuretic dose, ejection fraction and natriuretic peptide levels were similar. There was a trend toward worse CPX variables in pts Z0.63 [peak VO2 10.7 mL/kg/min (8.7-13.6) vs. 11.7 (9.5-14.0), P¼0.12; VE-VCO2 slope 46 (36-50) vs. 39 (34-49), P¼0.056]. Predicted 1 yr survival by SHFM was lower in pts Z0.63 [88% vs. 93%, P¼0.03]. Over a median follow-up of 264 days, observed outcomes were similar between groups (Figure).
S119 304 WITHDRAWN 305 Adaptation over a Wide Range of Donor Graft Lung Size Discrepancies in Living-Donor Lobar Lung Transplantation F. Chen, A. Ohsumi, H. Motoyama, K. Hijiya, T. Kondo, T. Yamada, M. Sato, A. Aoyama, T. Bando, H. Date. Thoracic Surgery, Kyoto University, Kyoto, Japan. Purpose: Unlike deceased donor lung transplantation, ideal size matching between donor and recipient is usually difficult because of the limited population of potential donors in living-donor lobar lung transplantation (LDLLT). As a result, there is a wide range of size discrepancies between donor and recipient in LDLLT. The aim of this study was to evaluate the function of the donor graft lung in the recipient thorax after LDLLT in 12 cases of bilateral LDLLT involving 24 successfully transplanted lower-lobe grafts. Methods and Materials: Pulmonary function tests and threedimensional computed tomography (3D-CT) volumetry were performed perioperatively. Results: Donor graft volume ranged from 40 to 161% of the hemilateral thoracic volume of the recipient. Graft forced vital capacities (FVC) increased over time, reaching 107 ⫾ 38% of preoperatively estimated values at 12 months after LDLLT. Graft volumes also increased over time, reaching 123 ⫾ 39% of the original values at 12 months postoperatively. As for the association between donor graft FVC ratio to the preoperatively estimated value at 12 months after LDLLT and 3D-CT volumetry size matching, there was a significant correlation between these parameters (r2 ¼ 0.31, p ¼ 0.005, Figure 1). In contrast, there was no significant correlation between donor graft volume ratio to the original value at 12 months after LDLLT and 3D-CT volumetry size matching (p ¼ 0.37, Figure 2). Undersized donor grafts expanded more after LDLLT than oversized donor grafts, producing greater FVCs than the preoperatively estimated values. In contrast, oversized donor grafts became inflated to their original size, and the FVCs also approached preoperatively estimated values. Six-minute walk distance dramatically improved at 3 months after LDLLT in both groups, reaching more than 500 m at 12 months postoperatively. Conclusions: In conclusion, we found that donor grafts overinflated or underinflated to the extent that they could maintain their own function in a new recipient environment. 306 Frailty and Early Mortality after Lung Transplantation: Preliminary Results D.J. Lederer, J.R. Sonett, N.A. Philip, M. Larkin, E.R. Peterson, A. Desai, S. Sanyal, L. Shah, H.A. Robbins, K. Raza, G. Reilly, F. D’Ovidio, M. Bacchetta, S.M. Arcasoy. Columbia University Medical Center, New York, NY.
Conclusions: Despite the belief that INTERMACS 4-5 pts may be ‘‘too well’’ for an LVAD, we found that 425% of these pts already displayed a marker for post-LVAD RVF. In pts with a CVP/ PCWPZ0.63, outcomes in the context of contemporary advanced HF therapies were similar vs. pts o0.63 despite worse predicted survival by the SHFM.
Purpose: Our group has hypothesized that the frailty phenotype might help identify those at high risk of early complications after lung transplantation. The prevalence of pre-transplant frailty among transplant recipients and the impact of frailty on outcomes after transplantation is not known. Methods and Materials: We performed an interim analysis of the first 46 consecutive lung transplant recipients Z50 years old enrolled in the Lung Transplant Body Composition (LTBC) study at our center. All LTBC participants undergo a structured frailty assessment during transplant evaluation. Frailty was defined as the presence of Z3 of the following: unintentional weight loss Z 4.5kg, low walking speed, selfreported exhaustion, low activity level, and low grip strength. Wilcoxon rank sum tests, Chi-square tests, Fisher’s exact tests, and log-rank tests were used to compare frail and non-frail participants. Results: The mean (SD) age was 62 (5) yrs, 34% were Z 65 yrs, 44% were female, 13% were African-American, 54% had ILD, 14% had COPD, 2% had CF, 4% were underweight, 13% were obese, the
