Mechanical Circulatory Support in Special Populations

Renzo Y. Loyaga-Rendon MD.,PhD..Assistant Professor

Advanced Heart Failure SectionUniversity of Alabama at Birmingham

“Peripartum Cardiomyopathy”

PPCMP as Special Population

- Women

: It has been described in Caucasians, African Americans, Hispanics and Asians. However, the incidence in African Americans is considerably higher.

: Mean age 23-33. Approximately 60% are older than 30 years.

- Race

- Age

: - 2.5 - 5 cases per each 10 000 live births. - 1 case for every 3186 women delivering a baby. - 1350 women in the US are affected each year.

: Recovery of LV function on medical therapy.- At 6 months 60% improve EF and 45% normalize EF. - Transplant rates 5-11%. - 5% of Transplant recipients have PPCMP.

PPCMP as Special Population

- Incidence

- Clinical course

PPCMP as Special Population Post-transplant outcomes

Rasmusson et al, JHLT 2012;31:180-6

Rejection Sensitization Allograft failure Retransplantation

PPCMP as Special Population

Unknown pathophysiology

PPCMP, clinical course.

Time

LVEF

(%)

>55

35

Delivery

Symptom onset1 m 5 m 48-62%

MCS HTx

LVAD

37-45%LVAD/HTx

6-25%

45

25

15

Explant

• To describe the baseline characteristics of patients with PPCMP who received MCS.

• To compare the outcomes of PPCMP patients who received MCS with Non-PPCMP.

Objectives

Circ Heart Failure 2014;7:300-309

INTERMACS Women >14 yo

June 23, 2006 and March 31, 2012

Study Population

CharacteristicPPCMP Non-PPCMP* p

99 (7.9%) 1159 (92.1%)

Age (y) 32.9 ± 9.7 53.5 ± 13.0 <.0001

Race <.0001 African American 55 (55.6%) 362 (31.2%) White 39 (39.4%) 718 (62.0%) Other 5 (5.0%) 79 (6.8%)

Pre-implant comorbidities Diabetes Mellitus 21 (21.2%) 422 (36.5%) 0.002 Peripheral vascular disease 1 (1.0%) 131 (11.3%) 0.001 Cancer 2 (2.0%) 171 (14.9%) 0.0004

Patient characteristics

Device ImplantedPPCMP Non-PPCMP* p

0.2

LVAD 84 (84.8%) 1039 (89.6%) Continuous Flow 76 935 Pulsatile Flow 8 104 BiVAD 14 (14.1%) 107 (9.2 %) TAH 1 (1.0%) 13 (1.1 %)

Type of Durable Mechanical Circulatory Support

Implantation strategy PPCMP Non-PPCMP* p

0.002 BTT 36 (36.4%) 388 (33.5 %) BTC 49 (49.5%) 455 (39.3 %) DT 7 (7.1%) 275 (23.7 %) BTR 4 (4.0%) 23 (2.0 %) Other (Rescue) 3 (3.0%) 18 (1.5 %)

Implantation Strategy

INTERMACS Profile PPCMP Non-PPCMP* p

0.4 1 Cardiogenic shock 21 (21.2%) 253 (21.8 %) 2 Progressive decline 45 (45.5%) 471 (40.6 %) 3 Inotrope dependent 24 (24.2%) 266 (23.0 %) 4-7 Advanced HF 9 (9.1%) 169 (14.6 %)

Severity of Disease at Implantation(INTERMACS profile)

Unadjusted Survival

p = 0.01

85%83%

68%76%

64%

52%

Unadjusted Survival PPCMP vs. ICMP vs NICMP

Unadjusted Survival in PPCMPPulsatile vs. Continuous flow LAVD

88%85% 78%

48 %

25.5 %

20 %

6 %

Competing Outcomes in PPCMP

Why do PPCMP patients have an improved survival?

Acute Sub-acute Chronic p

(18, 18.6%) (20,20.6%) (59, 60.8%)

Age (y) 25.8±6.0 26.0±6.4 37.6±8.8 <.0001

Characteristics of PPCMP patients according to Heart Failure Duration

PPCMP (n=99)

Type of DeviceAcute Sub-acute Chronic p

(18, 18.6%) (20,20.6%) (59, 60.8%)

0.02 LVAD 12 (66.6%) 16 (80%) 54 (91.5%) BiVAD 6 (33.3%) 4 (20%) 4 (6.7%) TAH 0(0%) 0(0%) 1 (1.6%)

Type of Device implanted in PPCMP patients according to Heart Failure Duration

PPCMP (n=99)

Implant StrategyAcute Sub-acute Chronic p

(18, 18.6%) (20,20.6%) (59, 60.8%)

0.2 BTT 3 (16.6%) 7 (35%) 24 (40.6%) BTC 11 (61.1%) 12 (60%) 26 (44%) DT 1 (5.5%) 0(0%) 6 (10.1%) BTR 2 (11.1%) 1 (5%) 1 (1.6%) Other (rescue) 1 (5.5%) 0(0%) 2 (3.3)

Implantation strategy in PPCMP patients according to Heart Failure Duration

PPCMP (n=99)

INTERMACS profileAcute Sub-acute Chronic p

(18, 18.6%) (20,20.6%) (59, 60.8%)

0.011 Cardiogenic shock 9 (50.0%) 5 (25.0%) 7 (11.9%)2 Declining on inotropes 5 (27.8%) 11 (55.0%) 28 (47.5%)3 Inotrope dependent 4 (22.2%) 4 (20.0%) 16 (27.1%)4-7 Recurrent advanced HF 0(0.0%) 0 (0.0%) 8 (13.6%)

Severity of Heart Failure (INTERMACS PROFILE) in PPCMP patients according to Heart Failure

Duration

PPCMP (n=99)

Outcomes at 36 monthsAcute Sub-acute Chronic p

(18, 18.6%) (20,20.6%) (59, 60.8%)

0.08 Explant due to recovery 2 (11.1%) 2 (10.0%) 0 (0.0%) Death 2 (11.1%) 2 (10.0%) 10 (17.0%) Transplanted 8 (44.4%) 8 (40.0%) 17 (28.8%) Alive on support 6 (33.3%) 8 (40.0%) 32 (54.2%)

Outcomes at 36 months in PPCMP patients according to Heart Failure Duration

PPCMP (n=99)

Updated survival data

47%

56%

Comparison of survival in PPCMP women receiving Advanced Heart Failure Therapies

Surv

ival

(%)

Years1 2 3 4

Heart Transplant Vs. LVAD

79%

67%

57%

47%

Surv

ival

(%)

Years1 2 3 4

Heart Transplant Vs. LVAD

79%

67%

57%

47%

84%81%

78%75%

Surv

ival

(%)

Years1 2 3 4

Heart Transplant Vs. LVAD

79%

67%

57%

47%

84%81%

78%75%83%

73%68%

62%

Surv

ival

(%)

Years1 2 3 4

Heart Transplant Vs. LVAD

79%

67%

57%

47%

84%81%

78%75%83%

73%

68%62%

57%

70%

81%

87%

Conclusions

• Women with PPCMP represent an special population, who have improved survival after MCS.

• Heart transplantation is achieved in < 50% of PPCMP patients who received MCS.

• Explant due to recovery is rare in PPCMP.

Thank you

• Despite of over 20% of peripartum cardiomyopathy patients presenting in cardiogenic shock at the time of implantation, the 2 year survival of this cohort was greater than 80% at 2 years.!

• This improved survival is likely explained by the fewer comorbidities and younger age observed in PPCMP women.

Conclusions

• Unfortunately at 3 years, Heart Transplantation was achieved in less than 50% of peripartum cardiomyopathy women receiving MCS.

• Despite the seemingly favorable environment for recovery (acute onset, younger age, Non-ischemic etiology) the recovery was disappointingly uncommon (6%).

Conclusions

Duration of Heart FailurePPCMP Non-PPCMP* p

0.004

Acute (< 1 month) 18 (18.2%) 112 (9.7 %)Sub-acute (1- 12 months) 20 (20.2%) 149 (12.9 %)Chronic ( > 12 months) 59 (59.6%) 859 (74.1 %) Unknown 2 (2.0%) 39 (3.4 %)

Duration of Heart Failure prior to Device Implantation

Time post implant (months)

Surv

ival

(%)

PPCMP

Non - PPCMP

100

50

75

25

36 30 24 18 12 6

Predicted Survival in the PPPCMP and Non-PPCMP patients based on the prevalence of risk factors in the specific group

P < 0.05

Time post implant (months)

Surv

ival

(%)

PPCMP

Non - PPCMP

p = 0.07

100

50

75

25

36 30 24 18 12 6 0

Predicted Survival in the PPCMP and Non-PPCMP patients based on the overall prevalence of risk factors