The Journal of Heart and Lung Transplantation, 2016
Results: Positive CMV serology at the time of HT was noted in all 30 (100%) patients (D+/R+: n= 1... more Results: Positive CMV serology at the time of HT was noted in all 30 (100%) patients (D+/R+: n= 12; D+/R-: n= 15; D-R+: n= 3). The mean time to CMV infection from HT was 298 days. Mean GEP score at the time of diagnosis of CMV infection was significantly higher when compared to GEP score obtained at other visits (33.1 vs. 28.2, p < 0.001). In 39 visits which occurred during a CMV infection compared to 24 visits occurring after resolution of viremia, mean GEP score changed from 33.1 to 30.6, p= 0.08. There were 2 ACR (≥ 2R) with GEP scores 35 and 37, respectively at the time of CMV infection visits. Conclusion: These data further confirm that CMV infections in HT recipients are associated with an increase in GEP score that is independent of ACR, with a trend towards decrease in the score once viremia is resolved. The likely mechanism is immune activation/modulation of one or more of the 11 genes in the GEP signature. CMV status should be considered when clinically interpreting high GEP scores in HT patients.
The Journal of Heart and Lung Transplantation, 2012
pulmonary vascular disease. We investigated the effect of pre LVAD TPG on post transplant surviva... more pulmonary vascular disease. We investigated the effect of pre LVAD TPG on post transplant survival of patients (pts) bridged to transplant. Methods and Materials: 490 pts were implanted with HeartMate II LVAD in the multicenter BTT clinical trial. 416/490 (85%) had TPG data available for analysis. TPG was calculated as the difference between mean pulmonary arterial pressure and pulmonary capillary wedge. Pts were divided into two groups based on the median TPG value. Results: The median TPG of all pts was 10 mmHg. Pts age (50Ϯ13 vs. 51Ϯ12), sex, co morbidities, renal and hepatic function, and pre-HTX LVAD support times (239 Ϯ 264 days vs. 262 Ϯ 264 days) did not differ between groups. Overall, there were no differences in LVAD outcomes (Recovery, HTX, or ongoing support) for pts below median TPG (Յ10 mmHg) and those above median TPG (Ͼ10 mmHg). However, one year post HTX survival for pts with TPG below the median value (Յ10 mmHg) was significantly higher (94%) than for those patients with TPG Ն10 mmHg (82%) (pϭ0.006). Analysis based on median PVR of 2.69 or upper quartile PVR of 3.8 did not reveal any differences between LVAD outcome of the groups or their post HTX survival. (91% vs 86% pϭ0.308, and 90% vs 84% pϭ0.3 respectively). Conclusions: Elevated TPG prior to LVAD implantation rather than high PVR, is associated with worse 1-year survival in HTX recipients. Elevated TPG appears as an important risk factor for post HTX mortality and therefore should be taken into consideration when contemplating heart transplant versus LVAD destination therapy in patients with advanced CHF.
The Journal of Heart and Lung Transplantation, 2013
average of 10 hemoglobin (Hgb) measurements in the first transplant year: Hgb 4 13 g/dL, Hgb 11-1... more average of 10 hemoglobin (Hgb) measurements in the first transplant year: Hgb 4 13 g/dL, Hgb 11-13 g/dL, and Hgb o 11 g/dL. Endpoints were 5-year survival, freedom from cardiac allograft vasculopathy (CAV), and non-fatal major adverse cardiac events (NF-MACE; myocardial infarction, heart failure, percutaneous intervention, stroke). Multivariate analysis was used to assess effect of recipient age, donor age, sex, Cr, desensitization pre-transplantation, diabetes, and induction therapy on the relationship between anemia and survival. Results: Chronic anemia did not impact post-transplant 5-year survival, CAV, or NF-MACE (Table). In the multivariate analysis, Cr had the strongest impact on survival. For every 1 mg/dL increase in Cr, there was a 4.3-fold increase in the risk of death (p ¼ 0.027). Conclusions: Chronic anemia in the first year does not impact survival after heart transplantation. However, even in a population of heart transplant recipients with normal creatinine, higher serum creatinine increases the risk of death post-transplantation. Further study is needed to determine if protocols to minimize renal insufficiency will improve outcomes in these patients.
The Journal of Heart and Lung Transplantation, 2016
infection. PET was considered positive if there was a focal area of heterogenous increased metabo... more infection. PET was considered positive if there was a focal area of heterogenous increased metabolic activity within the VAD, around cannulas or along the internal driveline or driveline exit site. There were forty-four VAD recipients that were studied in total. Results: Conclusion: PET accurately diagnosed infection (90.48%) and freedom from infection (78.2%) in VAD recipients. This data endorses the use of PET to diagnose VAD related infections. In the several cases where PET was positive and cultures were negative, this may represent inflammation. Culture positivity with negative PET imaging may represent non-VAD infection. Further investigation will seek to prognosticate VAD related infection and evaluate medical and surgical therapy efficacy for VAD infection. Early detection of VAD infection, by PET, may reduce morbidity and mortality related to complex medical and surgical care of infected VAD recipients.
The Journal of Heart and Lung Transplantation, 2017
Results: 17,057 HTX recipients were identified for whom 10,343 donors (60.6%) were given vasopres... more Results: 17,057 HTX recipients were identified for whom 10,343 donors (60.6%) were given vasopressin within 24 hours pre-cross clamp. KM analysis showed no significant 1-year survival difference between the stratified groups: 10% for users vs. 10.6% for non-users (p = 0.29), a finding confirmed in the adjusted model. Conclusion: Donor use of arginine vasopressin had no significant effect on the 1-year survival among HTX recipients. We believe that the use of vasopressin leading up to the time of organ removal should not negatively affect the heart procurement rates.
The Journal of Heart and Lung Transplantation, 2016
Results: Positive CMV serology at the time of HT was noted in all 30 (100%) patients (D+/R+: n= 1... more Results: Positive CMV serology at the time of HT was noted in all 30 (100%) patients (D+/R+: n= 12; D+/R-: n= 15; D-R+: n= 3). The mean time to CMV infection from HT was 298 days. Mean GEP score at the time of diagnosis of CMV infection was significantly higher when compared to GEP score obtained at other visits (33.1 vs. 28.2, p < 0.001). In 39 visits which occurred during a CMV infection compared to 24 visits occurring after resolution of viremia, mean GEP score changed from 33.1 to 30.6, p= 0.08. There were 2 ACR (≥ 2R) with GEP scores 35 and 37, respectively at the time of CMV infection visits. Conclusion: These data further confirm that CMV infections in HT recipients are associated with an increase in GEP score that is independent of ACR, with a trend towards decrease in the score once viremia is resolved. The likely mechanism is immune activation/modulation of one or more of the 11 genes in the GEP signature. CMV status should be considered when clinically interpreting high GEP scores in HT patients.
The Journal of Heart and Lung Transplantation, 2012
pulmonary vascular disease. We investigated the effect of pre LVAD TPG on post transplant surviva... more pulmonary vascular disease. We investigated the effect of pre LVAD TPG on post transplant survival of patients (pts) bridged to transplant. Methods and Materials: 490 pts were implanted with HeartMate II LVAD in the multicenter BTT clinical trial. 416/490 (85%) had TPG data available for analysis. TPG was calculated as the difference between mean pulmonary arterial pressure and pulmonary capillary wedge. Pts were divided into two groups based on the median TPG value. Results: The median TPG of all pts was 10 mmHg. Pts age (50Ϯ13 vs. 51Ϯ12), sex, co morbidities, renal and hepatic function, and pre-HTX LVAD support times (239 Ϯ 264 days vs. 262 Ϯ 264 days) did not differ between groups. Overall, there were no differences in LVAD outcomes (Recovery, HTX, or ongoing support) for pts below median TPG (Յ10 mmHg) and those above median TPG (Ͼ10 mmHg). However, one year post HTX survival for pts with TPG below the median value (Յ10 mmHg) was significantly higher (94%) than for those patients with TPG Ն10 mmHg (82%) (pϭ0.006). Analysis based on median PVR of 2.69 or upper quartile PVR of 3.8 did not reveal any differences between LVAD outcome of the groups or their post HTX survival. (91% vs 86% pϭ0.308, and 90% vs 84% pϭ0.3 respectively). Conclusions: Elevated TPG prior to LVAD implantation rather than high PVR, is associated with worse 1-year survival in HTX recipients. Elevated TPG appears as an important risk factor for post HTX mortality and therefore should be taken into consideration when contemplating heart transplant versus LVAD destination therapy in patients with advanced CHF.
The Journal of Heart and Lung Transplantation, 2013
average of 10 hemoglobin (Hgb) measurements in the first transplant year: Hgb 4 13 g/dL, Hgb 11-1... more average of 10 hemoglobin (Hgb) measurements in the first transplant year: Hgb 4 13 g/dL, Hgb 11-13 g/dL, and Hgb o 11 g/dL. Endpoints were 5-year survival, freedom from cardiac allograft vasculopathy (CAV), and non-fatal major adverse cardiac events (NF-MACE; myocardial infarction, heart failure, percutaneous intervention, stroke). Multivariate analysis was used to assess effect of recipient age, donor age, sex, Cr, desensitization pre-transplantation, diabetes, and induction therapy on the relationship between anemia and survival. Results: Chronic anemia did not impact post-transplant 5-year survival, CAV, or NF-MACE (Table). In the multivariate analysis, Cr had the strongest impact on survival. For every 1 mg/dL increase in Cr, there was a 4.3-fold increase in the risk of death (p ¼ 0.027). Conclusions: Chronic anemia in the first year does not impact survival after heart transplantation. However, even in a population of heart transplant recipients with normal creatinine, higher serum creatinine increases the risk of death post-transplantation. Further study is needed to determine if protocols to minimize renal insufficiency will improve outcomes in these patients.
The Journal of Heart and Lung Transplantation, 2016
infection. PET was considered positive if there was a focal area of heterogenous increased metabo... more infection. PET was considered positive if there was a focal area of heterogenous increased metabolic activity within the VAD, around cannulas or along the internal driveline or driveline exit site. There were forty-four VAD recipients that were studied in total. Results: Conclusion: PET accurately diagnosed infection (90.48%) and freedom from infection (78.2%) in VAD recipients. This data endorses the use of PET to diagnose VAD related infections. In the several cases where PET was positive and cultures were negative, this may represent inflammation. Culture positivity with negative PET imaging may represent non-VAD infection. Further investigation will seek to prognosticate VAD related infection and evaluate medical and surgical therapy efficacy for VAD infection. Early detection of VAD infection, by PET, may reduce morbidity and mortality related to complex medical and surgical care of infected VAD recipients.
The Journal of Heart and Lung Transplantation, 2017
Results: 17,057 HTX recipients were identified for whom 10,343 donors (60.6%) were given vasopres... more Results: 17,057 HTX recipients were identified for whom 10,343 donors (60.6%) were given vasopressin within 24 hours pre-cross clamp. KM analysis showed no significant 1-year survival difference between the stratified groups: 10% for users vs. 10.6% for non-users (p = 0.29), a finding confirmed in the adjusted model. Conclusion: Donor use of arginine vasopressin had no significant effect on the 1-year survival among HTX recipients. We believe that the use of vasopressin leading up to the time of organ removal should not negatively affect the heart procurement rates.
Uploads
Papers by V. Manfredini