Mechanical Circulatory Support in Special Populations Renzo Y. Loyaga-Rendon MD.,PhD.. Assistant Professor Advanced Heart Failure Section University 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 Approximately 60% are older than 30 years. - Race - Age

: cases per each live births. - 1 case for every 3186 women delivering a baby 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 onset 1 m 5 m 48-62% MCS HTx LVAD 37-45% LVAD/HTx 6-25% 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:

INTERMACS Women >14 yo June 23, 2006 and March 31, 2012 Study Population

Characteristic PPCMPNon-PPCMP* p 99 (7.9%)1159 (92.1%) Age (y)32.9 ± ± 13.0 <.0001 Race <.0001 African American55 (55.6%)362 (31.2%) White39 (39.4%)718 (62.0%) Other5 (5.0%)79 (6.8%) Pre-implant comorbidities Diabetes Mellitus21 (21.2%)422 (36.5%) Peripheral vascular disease1 (1.0%)131 (11.3%) Cancer2 (2.0%)171 (14.9%) Patient characteristics

Device Implanted PPCMPNon-PPCMP*p 0.2 LVAD84 (84.8%)1039 (89.6%) Continuous Flow76935 Pulsatile Flow8104 BiVAD14 (14.1%)107 (9.2 %) TAH1 (1.0%)13 (1.1 %) Type of Durable Mechanical Circulatory Support

Implantation strategy PPCMPNon-PPCMP*p BTT36 (36.4%)388 (33.5 %) BTC49 (49.5%)455 (39.3 %) DT7 (7.1%)275 (23.7 %) BTR4 (4.0%)23 (2.0 %) Other (Rescue)3 (3.0%)18 (1.5 %) Implantation Strategy

INTERMACS Profile PPCMPNon-PPCMP*p Cardiogenic shock21 (21.2%)253 (21.8 %) 2 Progressive decline45 (45.5%)471 (40.6 %) 3 Inotrope dependent24 (24.2%)266 (23.0 %) 4-7 Advanced HF9 (9.1%)169 (14.6 %) Severity of Disease at Implantation (INTERMACS profile)

Unadjusted Survival p = % 83% 68% 76% 64% 52%

Unadjusted Survival PPCMP vs. ICMP vs NICMP

Unadjusted Survival in PPCMP Pulsatile vs. Continuous flow LAVD 88% 85% 78%

48 % 25.5 % 20 % 6 % Competing Outcomes in PPCMP

Why do PPCMP patients have an improved survival?

AcuteSub-acuteChronic p (18, 18.6%)(20,20.6%)(59, 60.8%) Age (y)25.8± ± ±8.8<.0001 Characteristics of PPCMP patients according to Heart Failure Duration PPCMP (n=99)

Type of Device AcuteSub-acuteChronic p (18, 18.6%)(20,20.6%)(59, 60.8%) 0.02 LVAD12 (66.6%)16 (80%)54 (91.5%) BiVAD6 (33.3%)4 (20%)4 (6.7%) TAH0(0%) 1 (1.6%) Type of Device implanted in PPCMP patients according to Heart Failure Duration PPCMP (n=99)

Implant Strategy AcuteSub-acuteChronic p (18, 18.6%)(20,20.6%)(59, 60.8%) 0.2 BTT3 (16.6%)7 (35%)24 (40.6%) BTC11 (61.1%)12 (60%)26 (44%) DT1 (5.5%)0(0%)6 (10.1%) BTR2 (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 profile AcuteSub-acuteChronic p (18, 18.6%)(20,20.6%)(59, 60.8%) 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%) 8 (13.6%) Severity of Heart Failure (INTERMACS PROFILE) in PPCMP patients according to Heart Failure Duration PPCMP (n=99)

Outcomes at 36 months AcuteSub-acuteChronic p (18, 18.6%)(20,20.6%)(59, 60.8%) 0.08 Explant due to recovery2 (11.1%)2 (10.0%)0 (0.0%) Death2 (11.1%)2 (10.0%)10 (17.0%) Transplanted8 (44.4%)8 (40.0%)17 (28.8%) Alive on support6 (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

Survival (%) Years Heart Transplant Vs. LVAD 79% 67% 57% 47%

Survival (%) Years Heart Transplant Vs. LVAD 79% 67% 57% 47% 84% 81% 78% 75%

Survival (%) Years Heart Transplant Vs. LVAD 79% 67% 57% 47% 84% 81% 78% 75% 83% 73% 68% 62%

Survival (%) Years 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 Failure PPCMPNon-PPCMP*p 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 %) Unknown2 (2.0%)39 (3.4 %) Duration of Heart Failure prior to Device Implantation

Time post implant (months) Survival (%) PPCMP Non - PPCMP 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) Survival (%) PPCMP Non - PPCMP p = Predicted Survival in the PPCMP and Non-PPCMP patients based on the overall prevalence of risk factors