Current Situation and Prognostic Evolution of Combined Heart-lung Transplantation in a European Union Country

Background

This study aims to evaluate the entire experience in heart-lung transplantation (HLTx) in a country of the European Union with 47 million inhabitants according to the etiologies that motivated the procedure.

Methods

A retrospective study on 1,751 consecutive transplants (HLTx: 78) was performed from 1990 to 2020 in two centers. Overall survival, adjusted for clinical profile and etiological subgroups, was compared. 7 subgroups were considered: 1) Cardiomyopathy with pulmonary hypertension (CM + PH). 2) Eisenmenger syndrome. 3) Congenital heart disease (CHD). 4) Idiopathic pulmonary arterial hypertension (IPAH). 5) Cystic fibrosis. 6) Chronic obstructive pulmonary disease (COPD)/Emphysema. 7) Diffuse interstitial lung disease (ILD).

Results

Early mortality was 44% and that of the rest of the follow-up was 31%. There were differences between HTLx and HTx in survival, also comparing groups with a similar clinical profile with propensity score (p= 0.04). Median survival was low in CM + PH (18 days), ILD (29 days) and CHD (114 days), intermediate in Eisenmenger syndrome (600 days), and longer in IPAH, COPD/Emphysema and cystic fibrosis.

Conclusion

HLTx has a high mortality. The etiological analysis is of the utmost interest to make the most of the organs and improve survival.

Cardiac allograft vasculopathy and acute rejection surveillance in the same procedure through a single vascular access. High volume center experience

Introduction

Cardiac Allograft Vasculopathy (CAV) and Acute Rejection (AR) surveillance after a Heart Transplant (HT) is based on the performance of Coronary Angiography (CAG) that requires arterial access and Endomyocardial Biopsy, normally Ventricular Right (RV-EMB), which requires venous access. Depending on the clinical indication, HT patients are referred to the cath lab to perform both procedures in the same day. We evaluated the effectiveness and safety of performing a Left Ventricular Endomyocardial Biopsy (LV-EMB) and a CAG with a single artery access.

Methods

We retrospectively analyzed HT patients referred to cath lab for surveillance of AR and CAV on the same day between January 2018 and March 2021. We compared the procedures performed with two accesses (Group 1; CAG + RV-EMB) versus procedures made with a single artery access (Group 2; CAG + LV-EMB).

Results

121 Procedures were performed within the indicated period, 96 (79.3%) belong to the double access group and 25 (20.7%) to the single access group. All procedures were successful and without major complications. There were only 2 cases of insufficient sample, one for each group. Baseline characteristics in both groups and AR or CAV presence were similar (table). Total procedure time (52.00±15.30 vs 33.36±18.69min) and fluoroscopic time (10.70±4.89 vs 6.84±1.82 min) were significantly shorter in the single access group (p<0.001 in both). The most used arterial access in group 2 was the right radial artery (15; 60%) followed by the right femoral artery (5; 20%).

Conclusions

Performing an endomyocardial biopsy and coronary angiography through a single arterial access is as effective and safe as with double access, arterial and additional venous. Procedure time and fluoroscopic time is significantly less when it is performed through the same access.

Funding Acknowledgement

Type of funding sources: None.

Prospective evaluation of donor-derived cell-free DNA as a potential biomarker for cardiac allograft vasculopathy

Background

Cardiac allograft vasculopathy (CAV) remains a major cause of morbidity and mortality among long-term heart transplant (HT) recipients. There is clearly an unmet need for a noninvasive biomarker of CAV that could obviate the need to perform surveillance coronary angiograms in these patients.

Purpose

Our aim was to evaluate the performance of Donor-derived Cell Free DNA (dd-cfDNA) as a biomarker of CAV.

Methods

We prospectively measured dd-cfDNA levels in all consecutive asymptomatic patients undergoing surveillance coronary angiography >1 year after HT at a single center, between Jan 2019 and Jan 2021. Endpoints included the association between dd-cfDNA levels and the presence CAV, according to ISHLT 2010 classification. Patients with history of acute cellular rejection ≥1R or antibody mediated rejection in the previous 6 months were excluded.

Results

We included 94 HT recipients, median age 57 years (IQR 50–67), 67% men, a median of 10.9 years after transplant. Coronary angiogram revealed CAV0, CAV1, CAV2 and CAV3 in 61%, 19%, 14% and 6% of patients, respectively. Median dd-cfDNA values for each CAV group were: CAV0 0.92% (IQR 0.46–2.0), CAV1 1.4% (0.38–2.8), CAV2 0.17% (0.07–0.52) and CAV3 0.24% (0.057–0.87); p=0.0535. Figure 1 summarizes baseline characteristics of the cohort and results.

Comparison of dd-cfDNA levels in patients with CAV0 and CAV1–2-3 did not show significant differences (0.92%, IQR 0.46–2.0 vs 0.46%, IQR 0.075–1.5, p=0.059) (Figure 2A), nor did the comparison between patients with stable CAV (no new coronary lesions since previous angiogram, n=77) and progressive CAV (patients with new coronary stenoses, n=17); median dd-cfDNA values were 0.735% (IQR 0.195–2.0) vs 0.9% (IQR 0.12–1.8), p=0.76 (Figure 2B). A subanalysis according to time after HT was also found non-significant: less than 5 years (p=0.95), 5 to 10 years (p=0.14) and more than 10 years after HT (p=0.16) (Figure 2C). The AUC ROC curve for the diagnosis of CAV revealed the lack of ability to predict the presence of any degree of CAV (AUC ROC = 0.38).

Conclusion

In our experience, dd-cfDNA did not perform as a useful biomarker to avoid surveillance coronary angiograms for CAV diagnosis.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Sociedad Madrileña de Trasplantes

Infective endocarditis after transcatheter aortic valve implantation

Introduction

Infective endocarditis (IE) is a potentially serious complication in patients with prosthetic heart valves. The objective of this study is to analyze and describe the incidence, baseline characteristics, risks factors and in-hospital evolution in IE after Transcatheter Aortic Valve Implantation (IE-TAVI).

Methods

All the TAVI implanted in our center since the beginning of the program have been included consecutively. Patients with a confirmed diagnosis of IE according to the “ESC Guidelines for the management of infective endocarditis” are identified and analyzed.

Results

331 TAVI have been implanted in our center from June 2009 to February 2021. IE-TAVI incidence in our series is 2.7% (n=9 cases). In baseline analysis, we observed that insulin dependent diabetes mellitus, Barthel Score and Pulmonary systolic pressure >50mmHg are significantly associated with the appearance of IE-TAVI (TABLE 1).

The most frequently microorganism is Enterococcus faecalis (44.4%; n=4) followed by Staphylococcus aureus (22.2%; n=2), Coagulase-negative staphylococci (22.2%; n=2) and Streptococcus viridans (11.1%; n=1).

77.8% of IE-TAVI (n=7) are Nosocomial IE or non-nosocomial healthcare-associated IE. 2 of them have been related to implantation (1 Enterococcus faecalis and 1 Coagulase-negative staphylococci) and 5 have been related to other interventions (2 after gastroscopy, 1 after percutaneous vascular intervention, 1 hemodialysis catheter infection and 2 unknown focus).

44.4% of IE-TAVI (n=4) were confirmed after performing Positron Emission Tomography (PET) scan. 3 cases (33.3%) were diagnosed with the initial Transthoracic Echocardiogram (TTE) and 2 cases (22.2%) were diagnosed after performing a Transesophageal Echocardiogram (TEE) (TABLE 2)

4 patients had an indication for surgery according to the ESC Guidelines (3 for persistent bacteremia and 1 for severe aortic regurgitation), but all were ruled out due to high surgical risk. Hospital mortality was 44.4% (n=4). The main predictor of hospital mortality was having an indication for surgery (p=0.028), which was present in 3 of the 4 deaths. The other death was due to digestive bleeding during hospitalization.

Conclusions

IE-TAVI is a serious disease with high in-hospital mortality. Insulin dependent diabetes mellitus, Barthel Score and Pulmonary systolic pressure >50mmHg are risk factors for IE-TAVI. PET-scan is the imaging test of choice when there were no echocardiographic findings. The main predictor of mortality is having an indication for surgery according to the ESC Guidelines.

Funding Acknowledgement

Type of funding sources: None.

Evaluation of left ventricular diastolic function in Marfan syndrome using speckle-tracking echocardiography

Background/Introduction

Previous studies using conventional echocardiographic measurements have reported subclinical left diastolic dysfunction in patients with Marfan syndrome (MFS). Certain speckle-tracking echocardiography (STE) derived parameters have shown good correlation with invasive measurements of LV relaxation.

Purpose

To evaluate diastolic function in Marfan patients using STE-derived parameters along with traditional diastolic measurements and compare them with healthy controls.

Methods

We consecutively included 127 MFS patients with normal LV ejection fraction and no previous cardiovascular surgery or significant valvular regurgitation. We also studied 38 healthy controls (age and sex-matched). We performed LV and LA strain analysis using 2D STE (QLAB 10, Philips). Echocardiographic parameters recommended to assess diastolic function (according to ASE/EACVI 2016 guidelines) were also considered.

Results

Reported use of BB/ARB was 28/39% in MFS patients. According to current guidelines, all participants had normal diastolic function. MFS patients showed lower TDI e' velocities (septal and lateral) and higher average E/e' ratio compared to controls, but still within normal range. Regarding STE-derived measurements, LVGLS, EDLSR and PALS were significantly reduced in MFS. E/EDLSR ratio was higher among MFS patients, reflecting impaired LV relaxation. Interestingly, E/LVGLS was not different between both groups.

Conclusion

STE-derived parameters showed impaired LV relaxation in MFS patients compared to controls. Our results suggest that STE derived parameters can be markers of early diastolic dysfunction and provide a better insight into Marfan-related cardiomyopathy.

STE derived parameters

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Programa de Actividades de I+D de la Comunidad de Madrid

Clinical outcomes of percutaneous coronary intervention in coronary allograft vasculopathy from single center experience

Background/Introduction

Cardiac allograft vasculopathy (CAV) is a leading cause of morbidity and mortality of heart transplant recipients. Percutaneous coronary intervention (PCI) is an alternative to medical treatment, however long-term data from large multicenter studies are scarce.

Purpose

To review clinical characteristics and outcomes of CAV undergoing PCI in our heart transplant series.

Methods

We analysed retrospectively 52 heart transplant recipients with CAV who underwent PCI from 2004 to 2020. Surveillance angiography was performed in 90% of stents. Stent restenosis (SR), stent thrombosis (ST), target lesion revascularization (TLR) and patient survival are reported.

Results

During study period, 124 lesions were treated. Primary success was obtained in 99% of lesions. Mean angiographic follow up was 37±47 months. A total of 31 (25%) stents presented events during follow-up: 24 SR, 7 ST. There were no differences between bare-metal stent (BMS) and drug-eluting stent (DES). We performed 16 (12.9%) TLR. There was no association between clinical and lesion-related features and TLR. Post-PCI survival was 75.3% at 5 and 55.7% at 10 years.. Cytomegalovirus (CMV) infection before development of CAV decreased survival in univariable analysis (p<0.016).

Conclusions

PCI with stent in CAV can be performed with high rates of primary success and low rate of complications, similar to non-transplant patients. Our series suggest that CMV infection can have negative impact in post-PCI survival, but further studies are needed.

Funding Acknowledgement

Type of funding source: None

Pulmonary hypertension and congenital heart disease: medical treatment and risk factors for survival

Background

Pulmonary arterial hypertension (PAH) is a common comorbidity in congenital heart disease (CHD) and significantly affects prognosis. There are four large clinical groups of CHD-related PAH: Eisenmenger syndrome, PAH associated with non-restrictive shunt, PAH associated with restrictive shunt and postoperative PAH. Our purpose was to study the clinical and prognostic differences among them.

Methods

The REHAP is a Spanish multicentre voluntary registry of patients over 14 years of age, which includes patients with CHD and PAH, starting in 2007. 664 patients were analyzed: Baseline characteristics, functional class, right catheterization data, treatment and survival were compared.

Results

664 patients were analyzed: characteristics are detailed in the table. Patients with Eisenmenger were more frequently treated with oral monotherapy as a first line therapy and received less frequently prostanoids during the follow-up. Patients with Eisenmenger had significantly better prognosis, with the best long-term survival of the 4 groups. In a cox regression model, postoperative PAH has a 1.7 hazard ratio (HR) (reference group: Eisenmenger) after adjustment for age (HR 1.02 p 0,001), functional class (HR NYHA III-IV 2.3 p<0,001), sex (p 0.8) and pulmonary vascular resistance (p 0.7).

Conclusion

The clinical classification of PAH associated with CHD defines both the baseline characteristics and the prognosis of patients. Outcome relates closely to functional class and type of PAH–CHD. Eisenmenger group, which has the most severe hemodynamics, is the one with the best prognosis despite a less aggressive treatment.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Ferrer, Janssen

P2620PIONEER-HF criteria ready for the prime time? Data from REDINSCOR II registry

Background

New treatment strategies are needed to improve the prognosis in acute heart failure (AHF), recently PIONEER-HF results have been published showing in a selected group of patients a potential use of sacubitril/valsartan with safety in this scenario

Purpose

To evaluate the impact of PIONEER-HF potential indication in daily practice after AHF hospitalization at discharge

Methods

We included a subgroup of 909 patients consecutively admitted with AHF between October 2013 and December 2014 from a national multicentre, prospective registry with the complete data for this analysis. In the trial left ventricular ejection fraction (LVEF) ≤40% and natriuretic peptides at admission with values of NT-ProBNP≥1600 pg/ml were needed to be included. The clinical and analytic stability at discharge to safely start sacubitril/valsartan was considered as MDRD estimated Glomerular Filtration Rate≥30 mL/min/1.73 m2, Systolic Blood Pressure ≥100 mmHg and Potassium ≤5.2 mmol/L.

Results

The mean age was 72.1±12.01 years. Of these, 373 (38.8%) were female, 734 (76,6%) were hypertensive, 462 (48.2%) had diabetes and 282 (29.9%) coronary artery disease. At admission atrial fibrillation was found in 403 patients (40.1%) and 409 (45%) had reduced LVEF. The mean levels of NT-ProBNP 7259.4±9437.1 pg/ml. In this group of patients, the in-hospital mortality was 28 (2.9%) and the 1 year follow up mortality was 197 (20.5%) and the heart failure rehospitalizations in 1 year were 303 (31,5%). In table 1 the percentage of patients that fulfil the needed criteria for the application of PIONEER HF is shown. In our registry 235 patients (25.9%) could be potential users of sacubitril/valsartan after the acute phase of hospitalization

Table 1 Elements to stablish indication Number of patients (%) NT-ProBNP ≥1600 pg/ml at admission 730 (80.3%) MDRD estimated GFR ≥30 mL/min/1.73 m2 at discharge 798 (87.8%) Systolic Blood Pressure ≥100 mmHg at discharge 755 (83.1%) Serum Potassium ≤5.2 mmol/L at discharge 856 (94.2%) Clinical and analytic stability at discharge 636 (70%) Left ventricular ejection fraction ≤40% 409 (45%) PIONEER HF Criteria 235 (25.9%) GFR: Glomerular Filtration Rate.

Conclusions

In our cohort of AHF patients around 1 out 4 could be treated with sacubitril/valsartan at discharge if we apply the PIONEER HF criteria in a contemporary setting, this finding could have potential implications in the prognosis and current costs of care in a population with high morbidity and mortality.

Acknowledgement/Funding

Heart Failure Program of the Red de Investigaciόn Cardiovascular del Instituto de Salud Carlos III, Madrid, Spain (RD12/0042) and FEDER

P2472Two-dimensional speckle tracking echocardiography in heart transplant patients: five year follow-up of right and left ventricular function

Background

Evolution of left and right ventricular (LV and RV) function after heart transplantation (HT) has not been well described. Our objective was to evaluate the normal evolution of echocardiographic parameters of both ventricles and to explore if there is a link between the decrease of strain values and acute rejection (AR) or coronary allograft vasculopathy (CAV)

Methods

We followed 29 HT recipients with serial echocardiograms performed between 2011 and 2018, with a median follow-up of 5 years. LV global longitudinal strain (LV GLS) was analyzed by speckle tracking in 12 LV segments in 4 and 2 chamber views, and RV free wall longitudinal strain (RV free Wall LS) was measured in 4 chamber view. Acute rejection was diagnosed by EMB following our HT protocol. We take into consideration only moderate or severe rejection episodes (grade ≥2R).The presence of CAV was studied by coronariography or IVUS one year post-HT.

Results

As shown in the table below, LVEF was preserved from the begining of the follow up while LV GLS reached the normality in the 6th month, and both remained in normal ranges untill the 5th year. Regarding RV function, TAPSE was impaired in the early post-HT period and increased progressively and reached normality 1 year after HT. RV lateral wall LS rose during follow-up as well, reaching normal values 6 months after HT. Nevertheless, we noticed an impairment in this parameter at 5 years (−20.1±2.7, p=0.001), although it remained within normal ranges compared to guidelines reference parameters. We did not find any correlation between any parameter evaluated and the presence of AR or CAV at five years of follow-up.

LV and RV function parameters LVEF LV GLS TAPSE FAC RV free wall LS Basal (14 days) 63.0±7.9 −17.2±3.6 12.1±2.9* 43.7±9.8 −19.3±4.2 3 months 65.0±8.6 −17.7±2.8 14.8±3.4* 45.3±8.2 −22.0±4.6 6 months 65.8±9.6 −18.7±3.4 16.1±3.6 44.6±9.6 −24.6±4.9* 1 year 63.5±8.1 −18.1±2.2 17.1±4.1 44.0±8.1 −26.7±7.1* 2 years 63.8±6.8 −18.3±9.0 19.4±3.7 45.3±7.9 −27.6±6.3* 5 years 64.4±7.3 −18.1±3.3 17.9±3.9 46.6±12.1 −20.1±2.8 P (Anova) 0.85 0.85 <0.001 0.82 <0.001

Conclusion

As we show in this series of HT recipients with uneventful postoperative course, all LV and RV function parameters showed normal values 1 year after HT and manteined them during long-term follow-up. The presence of AR or CAV did not have any influence in ventricular function.

Experience in anaesthetic management of non-cardiac surgery in patients with ventricular assist devices

Heart failure (HF) is a syndromic condition with a high incidence in current medicine. When the symptoms of HF progress, and become refractory, cardiac transplant is the best therapeutic option. However, due to the shortage of donors and the long waiting lists, many of those patients are candidates for implantation of ventricular assist devices as a bridge to the cardiac transplant, or when this is not an option, as a definitive therapy. A series of four clinical cases of patients with ventricular assist devices that required surgical intervention, is presented. Three of them were assisted with long-term care: two EXCOR (pulsatile and para-corporeal) and one HEARTWARE (non-pulsatile and intra-corporeal), and the last one with short-term assistance; CentriMag biventricular Levitronix. There is no significant literature on the peri-operative implications of these patients when they undergo urgent or scheduled surgery. The experience in our centre leads us to raise the need to determine a series of aspects: operation of each device, emphasising the correct placement of the cannulas during the surgery; the proper management of any medication, emphasising the importance of anticoagulant and anti-platelet therapies; the Pathophysiological changes at cardiopulmonary level due to the implantation of these devices; and the importance of the administration of a correct antibiotic therapy. Given the complexity of these cases, the limited experience in this field, and the few cases that exist in these situations, it is recommended to create protocols to ensure their proper management.

[Angina pectoris in the heart transplant recipient: evidence of reinnervation]

Heart transplantation involves the removal of a sick heart together with its innervation and replacement with a donor heart isolated from the control of the autonomous nervous system of the recipient, therefore being, functionally dennervated. Dennervation conditions several alterations in cardiac physiology, such as the inability to experience pain during myocardial ischemia, so that theoretically these patients cannot present angina pectoris. However, several reports have shown evidence of reinnervation with isolated cases of transplanted patients with angina pectoris having been reported. We describe the case of a transplanted patient who showed typical effort angina, vascular disease of the graft and data of sympathetic reinnervation demonstrated by cardiac gammagraphy with metayodo-benzilguanidina-I-123.

[Experimental endocarditis. Pathological anatomy of human endocarditis]

Experimental reproduction of human endocarditis in animal models has been based on the induction of structural lesions in valve endocardium using different methods. The primary lesion caused in this way is the so called non-bacterial thrombotic endocarditis. Its colonization is then induced by inoculation of microorganisms in the bloodstream. Freedman's modified method has been the most widespread model of this type. It has mainly been performed in rabbits with inoculation of Staphylococcus aureus or alpha-hemolitic Streptococcus. Experimental models of endocarditis have contributed to our knowledge of the pathogenic mechanisms, causative agents and predisposing factors of endocarditis. They have also allowed us to develop appropriate diagnostic, therapeutic and prophylactic measures for its management.