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ACC 2014: Highlights of Interest to ISHLT Members

Rey Vivo, MD
Fellow in Advanced Heart Failure and Transplant Cardiology
UCLA Advanced Heart Failure, Heart Transplantation and Mechanical Circulatory Support Program
David Geffen School of Medicine at UCLA
Los Angeles, CA, USA

Rita Jermyn, MD
Fellow in Advanced Heart Failure and Transplant Cardiology
Montefiore Medical Center
Albert Einstein College of Medicine
Bronx, NY, USA

Eugene DePasquale, MD
Associate Director, Outpatient Heart Transplantation
UCLA Advanced Heart Failure, Heart Transplantation and Mechanical Circulatory Support Program
David Geffen School of Medicine at UCLA
Los Angeles, CA, USA

The 2014 Scientific Sessions of the American College of Cardiology were held in Washington DC from March 29-31, 2014. Given the scope of the Scientific Sessions, it is challenging to attend all sessions relevant to ISHLT members. We present a meeting summary to highlight important studies presented in advanced heart failure, heart transplantation and mechanical circulatory support.

These late breaking clinical trial and registry presentations have the potential to significantly impact the care of patients with advanced heart disease including:

  1. MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy): Long-term follow up was reported in the MADIT-CRT trial in which the effect of CRT-D on long-term survival was evaluated in 1691 surviving patients (phase 1) and 854 patients enrolled in post-trial registries (NYHA Class I/II). At 7 years of follow up, the cumulative rate from any cause among patients with left bundle-branch block (LBBB) was 18% among those randomly assigned to CRT-D as compared to 29% among those randomly assigned to defibrillator only. CRT-D was not associated with benefit and possibly harm in those without LBBB. The authors conclude that in those with mild heart failure symptoms with LBBB and left ventricular dysfunction, early intervention with CRT-D was associated with significant long-term survival benefit. This study has subsequently been published - NEJM 2014 DOI: 10.1056/NEJMoa1401426.

  2. MSC-HF (Autologous Mesenchymal Stromal Cell Therapy in Heart Failure): In this trial, 59 patients with chronic ischemic heart failure despite maximal medical therapy without coronary revascularization as an option with LVEF < 45% and NYHA Class 2 to 3 were randomized 2:1 to autologous mesenchymal stromal cell therapy or placebo. Cells were obtained from patients and amplified in the laboratory, and then injected into ischemic viable myocardium. Of those randomized, 37 of 39 receiving cell therapy and 18 of 20 controls completed follow up at 6 months. At that time, mean LV end-systolic volume, LV ejection fraction, stroke volume and end-systolic myocardial mass had improved significantly in the cell therapy group, both with respect to baseline and the control group. However, improvements were noted in NYHA class, six-minute-walk and quality of life in both groups. Notably, the sample size is small and improvement in ejection fraction was by a five-percentage point increase. It is unclear whether the gains noted in this study translate into clinical benefit. Further study is needed.

  3. Factors associated with hospital length of stay in acute heart failure in the United States. Sharma PP, Yu AT, Johnson KW et al.
    In this cross-sectional study of the 2011 NIS from the Healthcare Cost and Utilization Project the length of stay and cost of heart failure hospitalization is examined closely. Patients are divided into those admitted for < 4 days, 4 to 7 days and > 7 days. Discharged with stays > 7 days had higher percentage of comorbidities (i.e. renal insufficiency, COPD). In addition, adjusted costs were close to 2-fold and 5-fold higher for hospitalization with stays 4 to 7 days and > 7 days, respectively, compared to < 4 days.

Additional presentations of interest to ISHLT members include the following:

  1. 30-Day Readmissions in Continuous-Flow Left Ventricular Assist Device Patients Are a Marker for Adverse Outcomes. Sayer G, Cotts W, Macaluso G et al.
    In this single-center study, Sayer et al examined their cohort of LVAD patients implanted between 2005-2013 to evaluate the causes of 30-day (30d) readmissions and their association with long-term outcomes. Among 239 patients (mean age 60, 77% male, 82% destination therapy) with a median follow-up of 1.3 years, 29% were readmitted within 30 days. The most common causes of 30d readmission were GI bleeding (21%), infection (16%) and HF (13%). Regression analysis showed that 30d readmission significantly predicted readmission rate (β=4.0, p<0.001). In Kaplan-Meier analysis, survival was worse in patients with a 30d readmission. The results demonstrate that 30d readmissions are common in LVAD patients and are associated with a high rate of subsequent admissions as well as increased mortality. These findings suggest that readmitted LVAD patients may need to be more closely monitored for adverse outcomes.

  2. The Total Artificial Heart: An Effective Bridge to Transplantation in Patients with Advanced Heart Failure. Gurudevan SV, Arabia F, Esmailian F et al.
    This is the largest single center series of patients supported with the total artificial heart (TAH). Gurudevan et al evaluated the clinical outcomes of 22 patients with end-stage heart failure who were referred for heart transplantation (HT) and underwent implantation of the Syncardia TAH (Syncardia Systems, Tucson, AZ) as a bridge strategy. Mean LVEDD was 60 mm and mean LV ejection fraction was 24%; right ventricular function was normal in 5 patients, but mildly, moderately and severely depressed in 9, 2 and 6 patients, respectively. There were a total of 7 deaths (32%). 3 patients had cerebrovascular accidents and there were no device-related infections. 5 successfully underwent HT, while the remaining 10 patients are alive and awaiting a donor organ. 36% were discharged home with a portable home drive-line. This data reveals that the TAH may be considered as an effective bridge strategy to HT and may allow patients to wait at home.

  3. Cardiac Retransplantation: How Far Have We Come? DePasquale E, Cheng R, Nsair A et al.
    In this single-center study, the outcomes of 1378 primary transplant and 95 redo transplant recipients were examined by era (1987-2001 & 2002-2012). Transplant vasculopathy was the most prevalent indication in the redo heart transplantation group. Overall, mortality was increased in the redo transplant group (HR 1.52, CI 1.15-2.02). However, in the more recent era survival is comparable to primary heart transplantation. The authors suggest that in selected patients redo heart transplantation is associated with comparable short and long-term outcomes as first-time heart transplantation.

  4. Pre-transplant Chemotherapy does not Affect Post-transplant Outcome in Patients Undergoing OHT for AL Cardiomyopathy. Sarswat N, Niehaus E, Tabtabai S et al.
    Working on the hypothesis that pre-HT chemotherapy (CTX) targeting clonal plasma cell light chain production may lead to improved survival (versus the conventional method of HT followed by CTX and autologous stem cell transplant), Sasrwat et al conducted a multinational database study spanning 7 HT centers that manage patients with heart failure due to AL cardiac amyloidosis. Among 103 patients, 89 (86%) were waitlisted for HT and 56 (64%) survived to HT. 44% of the waitlisted patients received plasma cell targeted chemotherapy with bortezomib, lenalidomide, melphalan, or cyclophosphamide. Chemotherapy use did not differ in waitlisted patients who survived to HT (45%) and those that died prior to HT (42%, p=1.0). Post HT infection rates were similar in +CTX (21%) and -CTX (14%, p=0.72). Post HT survival was similar in +CTX and -CTX patients.

  5. Severe Breathlessness at Rest is not the most important Presentation of Acute Heart Failure. Shoaib A, Kassianides X, Cleland J et al.
    Cleland and his colleagues from the United Kingdom performed a retrospective study examining patients who were short of breath at rest or comfortable at rest but breathless on slight exertion. The object of this presentation was to better identify, risk stratify, and classify heart failure patients by their symptoms. Interestingly, more patients died by 180 days after a heart failure presentation who were breathless on slight exertion rather than short of breath at rest. It was noted clinical trials may exclude this very sick group of patients by focusing on breathlessness rather than peripheral congestion.

  6. Survival in Adults Undergoing Primary Heart Transplant after Fontan Palliation. Reardon LC, DePasquale E, Cruz D et al.
    Heart transplant survival in pediatric and adult recipients with pretransplant failing Fontan physiology has previously reported to be significantly reduced with 77% one-year survival. In a single-center study, the outcomes of adult failing Fontan patients undergoing heart transplantation were examined. Of 744 recipients, 13 patients were identified between 2002 and 2013. In this cohort, 90-day and one-year survival was 100% with three-year survival of 83% and 5-year survival of 80%. The authors conclude that survival in this cohort in a modern era was similar to non-congenital patients at their center.

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

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