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Updates from the Annual Heart Failure Society of America (HFSA) Meeting

Robert T. Cole, MD, Assistant Professor, Division of Cardiology
Alanna Morris, MD, Assistant Professor, Division of Cardiology
Emory Center for Heart Failure Therapy and Transplantation
Atlanta, Georgia, USA
RTCOLE@emory.edu; aamorr3@emory.edu

The 17th annual scientific meeting of the Heart Failure Society of America (HFSA) was recently held in Orlando, FL, from September 22-25, 2013. The turnout for the meeting was fantastic and, as always, there were many posters and presentations of particular interest to the ISHLT community. While there simply isn't enough time to discuss all of the abstracts pertinent to ISHLT members, please enjoy a few of the highlights below!

Wait List Mortality is Higher for Female Heart Transplant Candidates - Abstract 207
(Morris AA, Veledar E, Cole R, et al.)

Morris and colleagues from Emory University analyzed outcomes in over 38,000 patients listed for heart transplant in the OPTN database from 1985 to 2012 to assess for differences in wait list mortality based on gender. After adjusting for a number of wait-list variables (age, weight, ABO group, inotropic support, balloon pump support, ICD wedge pressure > 15 mmHg, and creatinine), female gender was an independent risk factor for wait-list mortality or removal from the transplant list for being "too sick to transplant" (HR 1.14, 95% CI [1.04, 1.24], p=0.005). Upon further analysis, women on the transplant list during this time interval were statistically less likely to have an ICD and less likely to have an LVAD as bridge-to-transplant. This may account for their higher wait-list mortality, but more work needs to be done to assess this.

Race and Worsening Renal Function after Solid Organ Transplantation - Abstract 051
(Lanfear D, Shafiq A, Peterson E, et al.)

In light of the well-recognized nephrotoxicity associated with calcineurin inhibitors post-transplant, Lanfear and colleagues at Henry Ford Hospital looked to determine if African-American transplant recipients had a higher burden of renal dysfunction compared to other races. They analyzed data from over 2,800 patients undergoing solid organ transplant between the dates of January 2000 and June 2012 to see if there was an association between TAC/CYA exposure and serial changes in creatinine by race. After adjusting for age, gender, HTN, and DM, they found that TAC exposure was associated with a greater rise in creatinine in African-Americans than other races. Over the study period, a 1 ng/ml rise in TAC level was associated with a 0.09 mg/dl rise in serum creatinine in African Americans, whereas this was associated with an improvement in renal function in non-African Americans (reduction in serum creatinine by 0.06, interaction p = 0.001). There was no difference in renal function changes for patients who received cyclosporine during that same time period.

The Impact of Lower Post-operative HMII Pump Speeds and Delayed Warfarin Initiation on Subsequent GI Bleeds - Abstract 047
(Carey S, Ng H, Sass D, et al.)

An all-too-familiar complication of continuous flow LVADs, the dreaded GI Bleed, occurs in as many as 22% of patients supported with HMII devices. There have been a number of strategies attempted to help reduce the burden of GI bleeding, including adjustments of pump speed and changing anticoagulation targets. Carey and colleagues out of Baylor University Medical Center (Dallas, TX) presented their success with a new strategy: immediate post-op speed reductions (starting speed 8400-8800) and delayed anticoagulation (warfarin initiation delayed until transfer out of CCU to telemetry, mean POD 3). Prior to this new strategy (6/2008 to 2/2012), patients at their center were started at a speed of 9200-9600 and had Coumadin started on POD 2. Their rates of GI bleeding during that period were 47% in women and 28% of men (at least one GI bleed) in 128 patients. Since the initiation of the low speed/delayed warfarin strategy, they have not had any GI bleeds in patients implanted from 2/2012 to 2/2013. Certainly a dramatic improvement, but longer follow-up will be necessary to see if these rates continue with this strategy.

Implantable Cardioverter-Defibrillators Are Not Associated with Survival in Patients with a Left Ventricular Assist Device - Abstract 167
(Sayer G, Bhat G, Gallagher C, et al.)

Sayer and colleagues from Advocate Christ Medical Center analyzed date on 215 patients with continuous-flow LVADs from 2005-2013 to determine if the presence of an ICD improved survival. Their study compared survival in 28 LVAD patients without an ICD to those with an ICD (n=187). 84% of the patients were implanted as destination therapy. After a median follow-up of 506 days, there was no statistically significant difference in survival between the ICD and non-ICD groups (HR 0.91; 95% CI [0.46 - 1.80] P=0.78). Of note, 13% of the patients with an ICD did receive appropriate shocks for VT, while 4% received inappropriate therapy for sinus tachycardia/SVTs.

Outcomes of Donor Hearts Offered for Transplantation, Declined by a Single Center and Transplanted at a Secondary Institution - Abstract 011
(Aulakh S, Cadeiras M, Biniwale R et al)

Aulakh and colleagues from UCLA Medical Center looked at outcomes for donor hearts that were declined at their center on the basis of quality. Compared to the 319 donor hearts (Group A, 61.8%) accepted at UCLA, 198 (Group B, 38.2%) eventually underwent transplantation at a different center. Declined hearts had significantly greater left ventricular hypertrophy (p=0.04), downtime events (p=0.06), CDC high risk status (p<0.01), and older donor age (p<0.01). Group B donors were more frequently accepted later in the donor offer sequence (p<0.01). Kaplan-Meier analysis revealed lower allograft survival in Group B at 30 days, but not at longer term follow up (median survival for both groups was 661 days). On multivariate analysis, higher sequence acceptance number was a predictor of poor outcomes (p=0.013). The authors concluded that since the early 30-day mortality seen with higher risk hearts was no longer significant at longer-term follow-up, criteria for acceptable donor hearts should be continuously evaluated in order to expand the donor pool.

Experience with Antithrombotic Therapy for Primary Treatment of LVAD Thrombosis - Abstract 170
(Morine K, Kiernan M, Kapur et al)

Morine and colleagues at Tufts Medical Center (Boston MA) retrospectively reviewed medical records of patients who received continuous flow LVADs at their institution from 1/2010 to 12/2012. LVAD thrombosis (LVAD-T) was suspected in 18 of 116 patients (incidence rate 0.15/patient-year) based on the presence of LDH >4 times upper limit of normal. Mean time to first occurrence of LVAD-T was 188 days (range 4-993). On presentation, 8 patients had abnormal power spikes, 7 had LVAD malfunction on ramped speed study, and 3 had symptomatic heart failure. Primary therapy for 11 patients was unfractionated heparin (UFH) while 7 were treated with bivalirudin. Due to lack of response among the 11 patients treated with UFH alone, 9 were later given eptifibatide/UFH (2), eptifibatide (1), bivalirudin (4), or tPA (2). Five patients first treated with bivalirudin were later treated with eptifibatide (1), tPA (1), or VAD exchange (3). Adverse events included 2 episodes of intracranial hemorrhage (1-UFH and 1-bivaluridin), one resulting in death, and 2 episodes of GI bleeding (1-eptifibatide/UFH and 1-eptifibatide). Twelve of the 18 patients (67%) were treated with anticoagulants alone, without the need for tPA or VAD exchange. Of the 12 patients successfully discharged following LVAD-T, there was recurrence in 7 (58%) patients leading to 11 readmissions. The authors concluded that despite the high morbidity associated with LVAD-T, carefully selected patients may be managed medically, although recurrence is common.

Role of C4d Staining in Endomyocardial Biopsies after Cardiac Transplantation - Abstract 176
(Bhat G, Siddiqua T, Aggarwal A et al)

Bhat and colleagues reviewed C4d staining in 583 endomyocardial biopsy (EMB) specimens from 36 consecutive heart transplant recipients over one year. Group 1 (n=8) had C4d positive biopsies at a median of 65 days (20-250) post-transplant, while Group 2 (n=28) had C4d negative biopsies. Acute cellular rejection (?1R) was more common in Group 1 patients (p=0.003), as was clinical suspicion of antibody mediated rejection (p=0.02) and donor-specific antibody (p=0.09). There was no difference in mortality between the two groups (p=0.8). The authors concluded that C4d in the presence of acute cellular rejection may be a biomarker for early or subclinical antibody mediated rejection, however more data is needed from a larger group of transplant patients.

Disclosure Statement: the authors have no conflicts of interest to disclose.

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