Effect of Pre-LVAD PVR on Heart Transplant Outcome

Size: px

Start display at page:

Download "Effect of Pre-LVAD PVR on Heart Transplant Outcome"

Dominic Allen
6 years ago
Views:

1 AATS 2015, VAD/ECMO Session Effect of Pre-LVAD PVR on Heart Transplant Outcome Masaki Tsukashita, MD, PhD, Hiroo Takayama, MD, PhD, Koji Takeda, MD, PhD, Jiho Han, BS, Sowmyashree Sreekanth, BS, Lauren Truby, BS, Paolo C. Colombo, MD, Melana Yuzefpolskaya, MD, Veli K. Topkara, MD, Arthur Reshad Garan, MD, Donna M. Mancini, MD, Paul A. Kurlansky, MD, Yoshifumi Naka, MD, PhD

2 DISCLOSURE Y. Naka has received consulting fees from Thoratec Corp. The remaining authors have no conflicts of interest to disclose.

3 BACKGROUND Fixed pulmonary hypertension (phtn) is often considered a contraindication to orthotopic heart transplantation (OHT). Two-thirds of transplant candidates present with phtn at the time of OHT evaluation. Several previous studies have demonstrated LVAD implantation decreased PVR and rendered patients with phtn eligible for OHT. These were mostly small studies varying in types of LVAD devices used (pulsatile or continuous-flow [CF]).

4 Pulmonary hypertension should be considered as a relative contraindication to cardiac transplantation when PVR > 5 Wood units PVRI > 6 TPG exceeds 16 to 20 mmhg

5 PURPOSE Investigate the effect of CF-LVAD support on phtn Analyze OHT outcomes in LVAD patients with pre-existing elevated PVR.

6 METHODS 256 potential OHT candidates underwent CF-LVAD implantation between March 2004 and December 2013 at NY-Presbyterian Hospital/. Pre-LVAD right heart catheterization data were available for 227 patients. Low PVR group (lpvr): PVR 3 Wood units (n = 106) Medium PVR group (mpvr): 3 < PVR < 5 Wood units (n = 76) High PVR group (hpvr): PVR 5 Wood units (n = 45)

7 Pre-LVAD patient characteristics Variables All patients lpvr mpvr hpvr p value Basic patient characteristics Patients (n) Age (years) 53.4 ± ± ± ± Female sex 41 (18.1%) 15 (14.2%) 13 (17.1%) 13 (28.9%) 0.09 BSA 1.97 ± ± ± ± Etiology of HF ICM 83 (36.6%) 38 (35.9%) 30 (39.5%) 15 (33.3%) DCM 129 (56.8%) 62 (58.5%) 42 (55.3%) 25 (55.6%) 0.71 others 15 (6.6%) 6 (5.7%) 4 (5.3%) 5 (11.1%)

8 Variables All patients lpvr mpvr hpvr p value Preop MCS 22 (9.7%) 15 (14.2%) 3 (4.0%) 4 (8.9%) 0.07 Preop IABP 58 (25.6%) 31 (29.3%) 17 (22.4%) 10 (22.2%) 0.49 Previous cardiac surgery 42 (18.5%) 15 (14.2%) 14 (18.4%) 13 (28.9%) 0.10 CABG 34 (15.0%) 11 (10.4%) 16 (21.1%) 7 (15.6%) 0.14 Mitral valve 13 (5.7%) 3 (2.8%) 3 (4.0%) 7 (15.6%) Tricuspid valve 3 (1.3%) 0 (0.0%) 0 (0.0%) 3 (6.7%) Aortic valve 4 (1.8%) 2 (1.9%) 2 (2.6%) 0 (0.0%) 0.6 Congenital 2 (0.90%) 1 (0.9%) 0 (0.0%) 1 (2.2%) 0.45

9 Hemodynamic Data Variables All patients lpvr mpvr hpvr p value LVEF (%) 15.2 ± ± ± ± Mean PAP (mmhg) 36.2 ± ± ± ± PCWP (mmhg) 24.1 ± ± ± ± TPG (mmhg) 12.1 ± ± ± ± C.O. (L/min) 3.30 ± ± ± ± PVR (WU) 3.59 ± ± ± ±

10 DEVICE TYPES 100% 90% 80% 70% 60% 50% 40% 30% 20% Jarvik 2000 Dura Heart DeBakey Ventrassist HeartWare HeartMate II 10% 0% total lpvr mpvr hpvr p=0.03

11 Kaplan-Meier survival curve during LVAD support p=0.24

12 PVR (Wood units) Changes over time in pulmonary vascular resistance lpvr mpvr hpvr Pre-LVAD Post-LVAD OHT 1y OHT 5y

13 Donor/recipient data for OHT Variables All patients lpvr mpvr hpvr p value (n = 148) (n = 72) (n = 47) (n = 29) Donor data Age (year) 29.4 ± ± ± ± ABO identical 89.1% 88.9% 89.1% 89.7% 0.99 ABO compatible 10.9% 11.1% 10.9% 10.3% Donor/recipient 0.99 ± ± ± ± weight Recipient data LVAD support 345 ± ± ± ± duration (days)

14 Intra- and postoperative data for OHT Variables All patients lpvr mpvr hpvr p value (n = 148) (n = 72) (n = 47) (n = 29) Intraoperative data CPB time (min) 176 ± ± ± ± Ischemic time (min) 189 ± ± ± ± Postoperative data ino usage 49 (33.6%) 25 (35.2%) 12 (25.5%) 12 (42.9%) 0.28 In-hosp mortality 13 (8.8%) 5 (6.9%) 2 (4.3%) 6 (20.7%) HD/CVVH 24 (16.4%) 8 (11.3%) 11 (23.9%) 5 (17.2%) 0.20 Primary graft failure 12 (8.2%) 7 (9.9%) 1 (2.2%) 4 (13.8%) 0.16

15 Kaplan-Meier survival curve after OHT p=0.43

16 Logistic regression of 30-day post-oht mortality variables Univariate analysis Multivariate analysis OR 95% CI p Value OR 95% CI p Value Age to Sex (Male) to BSA to ICM to HTN to to HM II (vs. others) to Pre-LVAD MCS to Pre-LVAD PVR > to to Post-LVAD PVR> to

17 CONCLUSION LVAD therapy significantly reduced PVR even in patients with severely elevated PVR. Early post-oht mortality in LVAD patients with preexisting high PVR was high. However, their long-term survival appeared comparable to that for patients with lower PVR.

A Validated Practical Risk Score to Predict the Need for RVAD after Continuous-flow LVAD

A Validated Practical Risk Score to Predict the Need for RVAD after Continuous-flow LVAD SK Singh MD MSc, DK Pujara MBBS, J Anand MD, WE Cohn MD, OH Frazier MD, HR Mallidi MD Division of Transplant & Assist