Pulmonary Artery Hypertension as A Risk Factor for Long-Term Survival after Heart Transplantation

Authors

  • Milos Matkovic, MD, PhD Department for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia
  • Vladimir Milicevic, MD Department for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia
  • Ilija Bilbija, MD Department for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia
  • Nemanja Aleksic, MD Department for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia
  • Marko Cubrilo, MD Department for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia
  • Emilija Nestorovic, MD, PhD Department for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia
  • Ana Antic, MD Department for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia
  • Mina Zlatkovic, MD Department for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia
  • Milos Velinovic, MD, PhD Department for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia
  • Svetozar Putnik, MD, PhD Department for Cardiac Surgery, University Clinical Center of Serbia, Belgrade, Serbia

DOI:

https://doi.org/10.1532/hsf.3789

Keywords:

Heart transplantation, pulmonary artery hypertension, survival, PVRI, TPG

Abstract

Background: Heart failure is the most frequent cause of pulmonary artery hypertension (PAH) and its severity may predict the development of heart failure (HF) and is known to be a prognostic factor of poor outcome after heart transplant (HTx). The aim of this study was to investigate the impact of preoperative PAH related to left-sided HF on long-term survival after HTx and to identify the hemodynamic parameters of PAH that predict survival after HTx.

Methods: A prospective observational trial was performed, and it included 44 patients subjected to heart transplantation. Patients were divided into two groups: The first one with the preoperative diagnosis of PAH and the second one without the PAH diagnosed prior to the HTx. The two groups were compared for baseline characteristics, operative characteristics, survival, and hemodynamic parameters obtained by right heart catheterization. Survival was analyzed using Kaplan Meyer analysis, and Cox regression analysis was performed to determine independent predictors of survival.

Results: The median follow-up time was 637.4 days (1-2028 days). The median survival within the group of patients with preoperative PAH was 1144 days (95% CI 662.884-1625.116) and 1918.920 days (95% CI 1594.577-2243.263) within the group of patients without PAH (P = .023), HR 0.279 (95% [CI]: 0.086-0.910; P = .034. The 30-day mortality in patients within PAH group was significantly higher, six versus two patients in the non PAH group (χ2 = 5.103, P < .05), while the long-term outcome after this period did not differ between the groups. Patients with preoperative PAH had significantly higher values of MPAP, PCWP, TPG and PVRI, while CO and CI did not differ between the two groups. Mean PVRI was 359.1 ± 97.3 dyn·s·cm-5 in the group with preoperative PAH and 232.2 ± 22.75 dyn·s·cm-5 in the group without PAH, P < .001. TPG values were 11.95 ± 5.08 mmHg in the PAH group while patients without PAH had mean values of 5.16 ± 1.97 mmHg, P < .001. Cox regression analysis was done for the aforementioned parameters. Hazard ratio for worse survival after HTx for elevated values of PVRI was 1.006 (95% [CI]: 1.001-1.012; P = .018) TPG had a hazard ratio of 1.172 (95% [CI]: 1.032-1.233; P = .015).

Conclusion: Pulmonary artery hypertension is an independent risk factor for higher 30-day mortality after HTx, while it does not affect the long-term outcome.
Hemodynamic parameters obtained by right heart catheterization in heart transplant candidates could predict postoperative outcome. PVRI and TPG have been identified as independent predictors of higher 30-day postoperative mortality.

References

Bourge RC, Kirklin JK, Naftel DC, White C, Mason DA, Epstein AE. 1991. Analysis and predictors of pulmonary vascular resistance after cardiac transplantation. J Thorac Cardiovasc Surg. 101(3): 432-444; discussion 444-435.

Butler J, Stankewicz MA, Wu J, et al. 2005. Pre-transplant reversible pulmonary hypertension predicts higher risk for mortality after cardiac transplantation. J Heart Lung Transplant. 24(2): 170-177.

Chang PP, Longenecker JC, Wang NY, et al. 2005. Mild vs severe pulmonary hypertension before heart transplantation: different effects on posttransplantation pulmonary hypertension and mortality. J Heart Lung Transplant. 24(8): 998-1007.

Costanzo MR, Dipchand A, Starling R, et al. 2010. The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients. J Heart Lung Transplant. 29(8): 914-956.

D'Alonzo GE, Barst RJ, Ayres SM, et al. 1991. Survival in patients with primary pulmonary hypertension. Results from a national prospective registry. Ann Intern Med 115(5): 343-349.

Delgado JF, Gomez-Sanchez MA, Saenz de la Calzada C, et al. 2001. Impact of mild pulmonary hypertension on mortality and pulmonary artery pressure profile after heart transplantation. J Heart Lung Transplant. 20(9): 942-948.

Erickson KW, Costanzo-Nordin MR, O'Sullivan EJ, et al. 1990. Influence of preoperative transpulmonary gradient on late mortality after orthotopic heart transplantation. J Heart Transplant. 9(5): 526-537.

Hosenpud JD, Bennett LE, Keck BM, Boucek MM, Novick RJ. 2000. The Registry of the International Society for Heart and Lung Transplantation: seventeenth official report-2000. J Heart Lung Transplant. 19(10): 909-931.

Klotz S, Wenzelburger F, Stypmann J, Welp H, Drees G, Schmid C, Scheld HH. 2006. Reversible pulmonary hypertension in heart transplant candidates: to transplant or not to transplant. Ann Thorac Surg. 82(5): 1770-1773.

Lindelow B, Andersson B, Waagstein F, Bergh CH. 1999. High and low pulmonary vascular resistance in heart transplant candidates. A 5-year follow-up after heart transplantation shows continuous reduction in resistance and no difference in complication rate. Eur Heart J. 20(2): 148-156.

Mehra MR, Canter CE, Hannan MM, et al. 2016. International Society for Heart Lung Transplantation Infectious Diseases, F. Heart and C. Transplantation. The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update. J Heart Lung Transplant. 35(1): 1-23.

Mehra MR, Kobashigawa J, Starling R, et al. 2006. Listing criteria for heart transplantation: International Society for Heart and Lung Transplantation guidelines for the care of cardiac transplant candidates--2006. J Heart Lung Transplant. 25(9): 1024-1042.

Moreira N, Baptista R, Costa S, Franco F, Pego M, Antunes M. 2015. Lowering pulmonary wedge pressure after heart transplant: pulmonary compliance and resistance effect. Arq Bras Cardiol. 105(3): 292-300.

Murali S, Kormos RL, Uretsky BF, et al. 1993. Preoperative pulmonary hemodynamics and early mortality after orthotopic cardiac transplantation: the Pittsburgh experience. Am Heart J. 126(4): 896-904.

Rabin J and Kaczorowski DJ. 2019. Perioperative Management of the Cardiac Transplant Recipient. Crit Care Clin. 35(1): 45-60.

Rivinius R, Helmschrott M, Ruhparwar A, et al. 2020. Elevated pre-transplant pulmonary vascular resistance is associated with early post-transplant atrial fibrillation and mortality. ESC Heart Fail. 7(1): 176-187.

Tenderich G, Koerner MM, Stuettgen B, et al. 1998. Does preexisting elevated pulmonary vascular resistance (transpulmonary gradient > 15 mm Hg or > 5 wood) predict early and long-term results after orthotopic heart transplantation? Transplant Proc. 30(4): 1130-1131.

Vakil K, Duval S, Sharma A, et al. 2014. Impact of pre-transplant pulmonary hypertension on survival after heart transplantation: a UNOS registry analysis. Int J Cardiol. 176(3): 595-599.

Vassileva A, Valsecchi O, Sebastiani R, Fontana A, Gamba A. 2013. Heterotopic heart transplantation for elevated pulmonary vascular resistance in the current era: long-term clinical and hemodynamic outcomes. J Heart Lung Transplant. 32(9): 934-936.

Published

2021-06-11

How to Cite

Matkovic, M., Milicevic, V., Bilbija, I., Aleksic, N., Cubrilo, M., Nestorovic, E., Antic, A., Zlatkovic, M., Velinovic, M., & Putnik, S. (2021). Pulmonary Artery Hypertension as A Risk Factor for Long-Term Survival after Heart Transplantation. The Heart Surgery Forum, 24(3), E544-E549. https://doi.org/10.1532/hsf.3789

Issue

Vol. 24 No. 3 (2021)

Section

Article
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