Long-term survival in patients with post-LVAD right ventricular failure: multi-state modelling with competing outcomes of heart transplant

BACKGROUND

Multicenter data on long term survival following LVAD implantation that make use of contemporary definitions of RV failure are limited. Furthermore, traditional survival analyses censor patients who receive a bridge to heart transplant. Here we compare the outcomes of LVAD patients who develop post-operative RV failure accounting for the transitional probability of receiving an interim heart transplantation.

METHODS

We use a retrospective cohort of LVAD patients sourced from multiple high-volume centers based in the United States. Five- and ten-year survival accounting for transition probabilities of receiving a heart transplant were calculated using a multi-state Aalen Johansen survival model.

RESULTS

Of the 897 patients included in the study, 238 (26.5%) developed post-operative RV failure at index hospitalization. At 10 years the probability of death with post-op RV failure was 79.28% vs 61.70% in patients without (HR 2.10; 95% CI 1.72 - 2.57; p = < .001). Though not significant, patients with RV failure were less likely to be bridged to a heart transplant (HR 0.87, p = .4). Once transplanted the risk of death between both patient groups remained equivalent; the probability of death after a heart transplant was 3.97% in those with post-operative RV failure shortly after index LVAD implant, as compared to 14.71% in those without.

CONCLUSIONS AND RELEVANCE

Long-term durable mechanical circulatory support is associated with significantly higher mortality in patients who develop post-operative RV failure. Improving outcomes may necessitate expeditious bridge to heart transplant wherever appropriate, along with critical reassessment of organ allocation policies.

Osteoblastic cells express phospholipid receptors and phosphatases and proliferate in response to sphingosine-1-phosphate

Sphingosine-1-phosphate (S1P) is a naturally occurring polar phospholipid that exerts growth-factor--like effects in a number of cell types, potentially by endocrine, paracrine, and intracrine mechanisms. The biological actions of S1P are mediated in part by its specific binding to at least four members of the edg/lp family of G protein-coupled receptors (edg 1, 3, 6, and 8), and further regulated by the actions of specific cell membrane-bound lipid phosphate phosphatases (LPPs). Recent evidence has suggested that S1P may act as an osteoblast growth factor. In the current study, we demonstrate expression in osteoblastic cells of the S1P receptors edg 1, edg 5 and edg 8; the lipid phosphate phosphatases LPP-1, LPP-2, and LPP-3, and the S1P phosphatase mSPP1. S1P exerts dose-dependent mitogenic effects in cultures of primary rat osteoblastic cells and SaOS-2 cells. S1P also activates p42/44 mitogen-activated protein (MAP) kinases in osteoblastic cells, and the proliferative effects of S1P in these cultures are partially abrogated by PD-98059 and U-0126, specific inhibitors of p42/44 MAP kinase signaling. S1P-induced p42/44 MAP kinase activation in osteoblastic cells is dependent on functional Gi proteins and intracellular calcium fluxes, but not on protein kinase A, phospha-tidylinositol-3 kinase, or protein Kinase C. These data demonstrate (1) the expression by osteoblastic cells of several cell membrane-bound components of phospholipid signaling and (2) that S1P is a potent osteoblast mitogen, the proliferative action of which is mediated by a signaling pathway that involves Gi proteins, intracellular calcium, and p42/44 MAP kinases.

Lysophosphatidic acid is an osteoblast mitogen whose proliferative actions involve G(i) proteins and protein kinase C, but not P42/44 mitogen-activated protein kinases

The simple glycerophospholipid lysophosphatidic acid (LPA) acts both as an intermediary in phospholipid metabolism and as an intercellular signaling molecule in its own right. In various cell types, LPA signals through its membrane-bound, G protein-coupled receptors to influence cellular processes such as proliferation, survival, and cytoskeletal function. Its actions in bone cells have not been studied. Here we show that the LPA receptor, LP(A1)/edg-2/vzg-1, is expressed in primary rat osteoblasts and the UMR 106-01 osteoblastic cell line. LPA potently induces DNA synthesis and an increase in cell number in cultures of osteoblastic cells. LPA rapidly (within 10 min) stimulates phosphorylation of p42/44 mitogen-activated protein (MAP) kinases in osteoblastic cells, an effect that is sensitive to inhibition of G(i) proteins, inhibition of influx of extracellular calcium, and inhibition of protein kinase C. LPA-induced DNA synthesis is partially inhibited by either pertussis toxin or calphostin C, but is insensitive to specific inhibitors of MEK, the kinase upstream of p42/44 MAP kinases, or of phosphatidylinositol-3 kinases. These data demonstrate that LPA is an osteoblast mitogen whose signaling effects in osteoblastic cells include activation of p42/44 MAP kinases. However, the LPA mitogenic signal in osteoblastic cells, while requiring G(i) proteins and protein kinase C, is independent of the activity of p42/44 MAP kinases.

The effect of leukemia inhibitory factor on bone in vivo

The local effects of leukemia inhibitory factor (LIF) on bone turnover in vivo have been examined. Recombinant murine LIF (0.2 micrograms) or vehicle was injected daily for 5 days over the right hemicalvaria, and the mice were killed on day 6 or 13. Effects on calvarial bone morphology were assessed using quantitative histomorphometry of nondecalcified bone tissue. Increased bone resorption was present in LIF-treated hemicalvaria compared with that in the noninjected hemicalvaria or calvaria from mice injected with vehicle alone at both 6 and 13 days. Significant increases in LIF-treated animals were as follows. Eroded surface increased 10-fold (P = 0.022), osteoclast surface increased 5-fold (P = 0.003), osteoclast numbers increased 3-fold (P = 0.002), and the number of osteoclast nuclei increased 3-fold (P = 0.009). Fibrotic tissue was laid down in the resorption defects, and there was an accompanying thickening of the periosteum (3 times greater in LIF-injected animals; P = 0.003), causing the overall thickness of the treated bones to be almost doubled (P = 0.045). Indices of bone formation were increased in animals treated with LIF. Osteoblast numbers, osteoblast surface, and osteoid area were doubled (P = 0.012, 0.016, and 0.058, respectively). Similar effects of LIF were seen in indomethacin-treated animals. Small but statistically significant morphological changes were also seen in the left noninjected hemicalvariae when LIF-treated animals were compared to controls. LIF increased periosteal area (P = 0.01) and total mineralized bone area (P = 0.002). In conclusion, LIF accelerated bone turnover locally in a prostaglandin-independent manner in normal mice, demonstrating its potential to modify in vivo bone cell function dramatically.

Regulation of osteoblast proliferation by leukemia inhibitory factor

We recently showed that leukemia inhibitory factor (LIF) stimulates 45Ca release from neonatal mouse calvariae in vitro and that it increases DNA and protein synthesis in this model. To elucidate further the actions of LIF on bone we now report the effects of this cytokine on DNA synthesis and cell proliferation in isolated fetal rat osteoblasts and in the osteogenic sarcoma cell line, UMR-106. In both actively growing and growth-arrested rat osteoblasts, LIF stimulated [3H]thymidine incorporation in a dose-dependent manner. The increase in DNA synthesis was time dependent, was associated with an increase in the number of osteoblasts, and was not blocked by indomethacin. LIF-treated cells showed reduced [3H]thymidine incorporation in comparison with control, as they approached confluence, possibly because of the increased cell density in the LIF-treated cultures. In UMR-106 cells, treatment with LIF inhibited [3H]thymidine incorporation in both actively growing and growth-arrested cultures. The effect was dose dependent and sustained with time. There was a corresponding decrease in cell numbers. It is concluded that although LIF causes an early stimulation of proliferation in isolated osteoblasts, it has opposing effects on UMR-106 cells. It is not possible to determine which of these effects is more relevant to the actions of LIF in vivo. The demonstration of a LIF effect on both these cell types, however, provides further evidence that this cytokine acts directly on osteoblasts.