Mechanical Circulatory Support in Special Populations

1
Mechanical Circulatory Support in Special
Populations
Peripartum Cardiomyopathy
Renzo Y. Loyaga-Rendon MD.,PhD.. Assistant
Professor Advanced Heart Failure
Section University of Alabama at Birmingham
2
PPCMP as Special Population
- Women
Mean age 23-33. Approximately 60 are older
than 30 years.
- Age
- Race
It has been described in Caucasians, African
Americans, Hispanics and Asians. However, the
incidence in African Americans is considerably
higher.
3
PPCMP as Special Population
- 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.
- Incidence
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.

• Clinical course

4
PPCMP as Special Population
Post-transplant outcomes

• ? Rejection
• Sensitization
• Allograft failure
• Retransplantation

Rasmusson et al, JHLT 201231180-6
5
PPCMP as Special Population
Unknown pathophysiology
6
PPCMP, clinical course.
gt55
45

LVEF ()
35
25
15
Time
7
Objectives
Circ Heart Failure 20147300-309

• 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.

8
Study Population
1258
9
Patient characteristics
Characteristic PPCMP Non-PPCMP p
Characteristic 99 (7.9) 1159 (92.1)  
Age (y) 32.9 9.7 53.5 13.0 lt.0001
Race lt.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
10
Type of Durable Mechanical Circulatory Support
Device Implanted PPCMP Non-PPCMP p
Device Implanted  
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 )
11
Implantation Strategy
Implantation strategy PPCMP Non-PPCMP p
Implantation strategy  
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 )
12
Severity of Disease at Implantation(INTERMACS
profile)
INTERMACS Profile PPCMP Non-PPCMP p
INTERMACS Profile  
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 )
13
Unadjusted Survival
85
83
68
76
64
52
p 0.01
14
Unadjusted Survival PPCMP vs. ICMP vs NICMP
15
Unadjusted Survival in PPCMP Pulsatile vs.
Continuous flow LAVD
88
85
78
16
Competing Outcomes in PPCMP
48
25.5
20
6
17
Why do PPCMP patients have an improved survival?
18
Characteristics of PPCMP patients according to
Heart Failure DurationPPCMP (n99)
Acute Sub-acute Chronic p
(18, 18.6) (20,20.6) (59, 60.8)  
Age (y) 25.86.0 26.06.4 37.68.8 lt.0001
19
Type of Device implanted in PPCMP patients
according to Heart Failure DurationPPCMP (n99)
Type of Device Acute Sub-acute Chronic p
Type of Device (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)
20
Implantation strategy in PPCMP patients according
to Heart Failure DurationPPCMP (n99)
Implant Strategy Acute Sub-acute Chronic p
Implant Strategy (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)
21
Severity of Heart Failure (INTERMACS PROFILE) in
PPCMP patients according to Heart Failure
DurationPPCMP (n99)
INTERMACS profile Acute Sub-acute Chronic p
INTERMACS profile (18, 18.6) (20,20.6) (59, 60.8)  
0.01
1 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)

22
Outcomes at 36 months in PPCMP patients
according to Heart Failure DurationPPCMP (n99)
Outcomes at 36 months Acute Sub-acute Chronic p
Outcomes at 36 months (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)

23
Updated survival data
56
47
24
Comparison of survival in PPCMP women receiving
Advanced Heart Failure Therapies
25
Heart Transplant Vs. LVAD
79
67
Survival ()
57
47
3
4
1
2
Years
26
Heart Transplant Vs. LVAD
84
81
78
75
79
67
Survival ()
57
47
3
4
1
2
Years
27
Heart Transplant Vs. LVAD
84
81
78
83
75
73
79
68
62
67
Survival ()
57
47
3
4
1
2
Years
28
Heart Transplant Vs. LVAD
87
84
81
81
78
83
75
73
70
79
62
68
67
Survival ()
57
57
47
3
4
1
2
Years
29
Conclusions

• Women with PPCMP represent an special population,
  who have improved survival after MCS.
• Heart transplantation is achieved in lt 50 of
  PPCMP patients who received MCS.
• Explant due to recovery is rare in PPCMP.

30
Thank you
31
(No Transcript)
32
Conclusions

• 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.

33
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).

34
Duration of Heart Failure prior to Device
Implantation
Duration of Heart Failure PPCMP Non-PPCMP p
Duration of Heart Failure  
0.004
Acute (lt 1 month) 18 (18.2) 112 (9.7 )
Sub-acute (1- 12 months) 20 (20.2) 149 (12.9 )
Chronic ( gt 12 months) 59 (59.6) 859 (74.1 )
Unknown 2 (2.0) 39 (3.4 )
35
Predicted Survival in the PPPCMP and Non-PPCMP
patients based on the prevalence of risk factors
in the specific group
100
PPCMP
75
Survival ()
Non - PPCMP
50
25
P lt 0.05
36
24
18
12
30
6
Time post implant (months)
36
Predicted Survival in the PPCMP and Non-PPCMP
patients based on the overall prevalence of risk
factors