Effect of Pre-LVAD PVR on Heart Transplant...

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

Columbia University Medical Center

Columbia UniversityMedical Center Division of

Cardiothoracic Surgery

AATS 2015, VAD/ECMO Session

DISCLOSURE

Y. Naka has received consulting fees from Thoratec Corp. The

remaining authors have no conflicts of interest to disclose.

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]).





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

PURPOSE

Investigate the effect of CF-LVAD support on

pHTN

Analyze OHT outcomes in LVAD patients with

pre-existing elevated PVR.



256 potential OHT candidates underwent CF-LVAD implantation

between March 2004 and December 2013 at NY-Presbyterian

Hospital/Columbia University Medical Center.

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)



METHODS

Pre-LVAD patient characteristics



Variables All patients lPVR mPVR hPVR p value

Basic patient characteristics

Patients (n) 227 106 76 45

Age (years) 53.4 ± 12.5 51.7 ± 13.3 55.5 ± 11.1 53.8 ± 12.3 0.29

Female sex 41 (18.1%) 15 (14.2%) 13 (17.1%) 13 (28.9%) 0.09

BSA 1.97 ± 0.3 1.99 ± 0.26 1.99 ± 0.26 1.87 ± 0.25 0.02

Etiology of HF

ICM 83 (36.6%) 38 (35.9%) 30 (39.5%) 15 (33.3%)

0.71DCM 129 (56.8%) 62 (58.5%) 42 (55.3%) 25 (55.6%)

others 15 (6.6%) 6 (5.7%) 4 (5.3%) 5 (11.1%)




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%) 0.006

Tricuspid valve 3 (1.3%) 0 (0.0%) 0 (0.0%) 3 (6.7%) 0.002

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


LVEF (%) 15.2 ± 6.1 14.7 ± 5.5 15.8 ± 7.2 15.2 ± 5.2 0.7

Mean PAP

(mmHg)

36.2 ± 10.4 31.9 ± 8.9 38.5 ± 9.8 42.3 ± 10.4 0.0001

PCWP (mmHg) 24.1 ± 8.5 24.0 ± 8.5 24.8 ± 8.9 23.0 ± 7.9 0.82

TPG (mmHg) 12.1 ± 6.5 7.98 ± 3.80 13.5 ± 5.2 19.2 ± 6.4 0.0001

C.O. (L/min) 3.30 ± 1.02 3.71 ± 0.99 3.17 ± 0.89 2.57 ± 0.83 0.0001

PVR (WU) 3.59 ± 2.23 1.91 ± 0.63 3.86 ± 0.55 7.13 ± 2.09 0.0001

Hemodynamic Data

DEVICE TYPES

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

total lPVR mPVR hPVR

Jarvik 2000

Dura Heart

DeBakey

Ventrassist

HeartWare

HeartMate II

p=0.03



Kaplan-Meier survival curve during LVAD support



p=0.24

Changes over time in pulmonary vascular resistance



0

1

2

3

4

5

6

7

8

9

10

Pre-LVAD Post-LVAD OHT 1y OHT 5y

PV

R (

Wo

od

un

its)

lPVR

mPVR

hPVR

Donor/recipient data for OHT



Variables All patients

(n = 148)

lPVR

(n = 72)

mPVR

(n = 47)

hPVR

(n = 29)

p value

Donor data

Age (year) 29.4 ± 9.2 28.2 ± 9.7 31.0 ± 8.2 30.4 ± 9.6 0.33

ABO identical 89.1% 88.9% 89.1% 89.7% 0.99

ABO compatible 10.9% 11.1% 10.9% 10.3%

Donor/recipient

weight

0.99 ± 0.17 0.98 ± 0.17 0.99 ± 0.15 1.03 ± 0.18 0.36

Recipient data

LVAD support

duration (days)

345 ± 343 328 ± 309 358 ± 372 362 ± 379 0.89

Intra- and postoperative data for OHT



Variables All patients

(n = 148)

lPVR

(n = 72)

mPVR

(n = 47)

hPVR

(n = 29)

p value

Intraoperative data

CPB time (min) 176 ± 54 175 ± 50 173 ± 43 184 ± 75 0.94

Ischemic time (min) 189 ± 51 187 ± 53 189 ± 46 195 ± 52 0.88

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%) 0.036

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

Kaplan-Meier survival curve after OHT



p=0.43

Logistic regression of 30-day post-OHT mortality



variables Univariate analysis Multivariate analysis

OR 95% CI p Value OR 95% CI p Value

Age 1.03 0.96 to 1.10 0.44

Sex (Male) 1.40 0.17 to 11.6 0.76

BSA 0.72 0.036 to 14.6 0.83

ICM 0.77 0.15 to 3.97 0.76

HTN 2.98 0.58 to 15.4 0.19 2.70 0.52 to 13.96 0.24

HM II (vs. others) 0.46 0.09 to 2.39 0.36

Pre-LVAD MCS 1.91 0.23 to 15.9 0.55

Pre-LVAD PVR > 5 5.88 1.32 to 26.3 0.02 5.53 1.23 to 24.8 0.03

Post-LVAD PVR>3 0.58 0.05 to 6.35 0.65

CONCLUSION



LVAD therapy significantly reduced PVR even in patients

with severely elevated PVR.

Early post-OHT mortality in LVAD patients with pre-

existing high PVR was high.

However, their long-term survival appeared comparable

to that for patients with lower PVR.

Columbia UniversityMedical Center

Division ofCardiothoracic Surgery

Effect of Pre-LVAD PVR on Heart Transplant...

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