September 21, 2018

Heart Transplant Recipients on LVAD Support at Higher Risk of Primary Graft Dysfunction and Death

By Lorraine L. Janeczko

NASHVILLE, Tenn -- September 21, 2018 -- Patients who rely on left-ventricular assist devices (LVADs) and develop early severe or late right heart failure (RHF) are more likely to have primary graft dysfunction (PGD) and die after cardiac transplantation, according to a retrospective chart review presented here at the 22nd Annual Meeting of the Heart Failure Society of America (HFSA).
“Given the striking increase in PGD and the increased vigilance for PGD, aggressive early haemodynamic support should be anticipated for these patients,” stated Phillip M. King, MD, Washington University School of Medicine, St. Louis, Missouri, and colleagues on September 17.

To investigate whether RHF may identify patients at a greater risk of complications after heart transplant while on LVAD support, the researchers reviewed the charts of 141 patients with durable, continuous-flow LVADs who underwent transplantation between 2010 and 2016 at 1 academic medical centre.

Forty-one patients developed RHF while on LVAD support. Their median age was 58 years, 78.7% were men, 74.5% were white, and 57% had nonischaemic cardiomyopathy.

RHF was defined as the need for a right-ventricular assist device, the use of inotropes beyond 14 consecutive days after the LVAD implant, the need to start using inotropes again after 14 days but before 30 days after LVAD, or heart failure that needed medical care >30 days after LVAD implantation discharge.

The researchers compared the incidence of PGD after transplant in patients who had RHF with the incidence of those who did not. They assessed 30-day survival, 1-year survival, vasoplegia incidence, PGD severity, and outcomes according to type of RHF.

The patients in the RHF group had a greater incidence of donor-recipient weight mismatch than the non-RHF group (14.6% vs 3.0%; P = .018) and a lower donor ejection fraction (55% vs 60%; P = .018) but no other significant baseline differences.

In the RHF group, 18 patients developed PGD, versus 14 patients in the non-RHF group (43.9% vs 14.0%, respectively; P< .001). Mortality was significantly higher at 30 days (19.5% vs 1.0%; P< .001, respectively) and 1 year (22.0% vs 6.0%, respectively; P = .013).

When stratified by RHF type, patients with only late RHF had a greater incidence of PGD (58% vs 17%; P< .001) and higher mortality at 30 days (21% vs 4%; P< .001). No difference in mortality was seen at 1 year (21% vs 9%; P = .121).

RHF was associated with almost 4 times the risk of PGD (odds ratio, 3.80; P = .001).

“Donor factors may further increase the risk of these outcomes and should be carefully assessed in this high-risk group,” advised the researchers.

[Presentation title: Right Heart Failure During Support With a Left Ventricular Assist Device Is Associated With Primary Graft Dysfunction After Heart Transplantation. Abstract 009]

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