Impact of Recipients Pre-Operative Right Ventricular Dysfunction on Heart Transplantation Outcomes

Abstract

Purpose To evaluate the impact of recipients pre-operative right ventricular dysfunction on heart transplantation (Htx) outcomes. Methods We retrospectively analyzed 517 consecutive adult patients who underwent Htx between January 2000 and December 2020, focusing on right heart catheter hemodynamic data, mostly. Results In-hospital mortality was 8%. Severe Early Graft Failure (EGF) occurred in 6.6% of patients. Right ventricular function and pulmonary circulation hemodynamic variables were weighted in terms of influence on in-hospital mortality: Central Venous Pressure (CVP) [OR 1.09 (1.03;1.15), p=0.004], Pulmonary Artery Systolic Pressure (PASP) [OR 1.02 (1.00;1.04), p=0.05], CVP/ Pulmonary Capillary Wedge Pressure (PCWP) ratio [OR 2.78 (1.14;6.80), p=0.025], Pulmonary Vascular Resistance (PVR) [OR 1.15 (1.01;1.32), p=0.042], Trans-Pulmonary Gradient (TPG) [OR 1.11 (1.03;1.18), p=0.003] and Diastolic Trans-Pulmonary Gradient (DPG) [OR 1.10 (1.02;1.20), p=0.015]. Thereafter, PASP [OR 1.03 (1.00;1.05), p=0.016] and TPG [OR 1.08 (1.01;1.17), p=0.03] did impact negatively on the occurrence of EGF. Preoperative right ventricular dysfunction did not result to influence on follow-up (FU) mortality. On the multivariable analysis, CVP and TPG resulted to be independent predictors of in-hospital mortality while TPG of EGF. By spitting patients population into 4 hemodynamic profiles in terms of pulsatile load, focusing on Pulmonary Artery Compliance (PACi), and right ventricle hemodynamic response to load, focusing on CVP:PCWP ratio, we resulted to have a high PACi/high PVC:PCWP profile with a higher risk of in-hospital mortality [OR 2.40 (1.04;5.54), p=0.05] and EGF [OR 3.40 (1.32;7.28), p= 0.01]. Overall survival at 1, 5 and 10 years was 89.4%, 80.8% and 66.4%, respectively. By analyzing the four hemodynamic profiles, patients with low PACi/high PVC:PCWP showed the worst survival (Log-rank=0.045). Conclusion In our patients population, CVP and TPG resulted to be independent risk factors of in-hospital mortality while TPG of EGF. Thus, the detection of pre-operative right ventricular dysfunction in potential heart transplant recipients should be managed early and treated properly in terms of preoperative clinical optimization to improve the postoperative outcomes. To evaluate the impact of recipients pre-operative right ventricular dysfunction on heart transplantation (Htx) outcomes. We retrospectively analyzed 517 consecutive adult patients who underwent Htx between January 2000 and December 2020, focusing on right heart catheter hemodynamic data, mostly. In-hospital mortality was 8%. Severe Early Graft Failure (EGF) occurred in 6.6% of patients. Right ventricular function and pulmonary circulation hemodynamic variables were weighted in terms of influence on in-hospital mortality: Central Venous Pressure (CVP) [OR 1.09 (1.03;1.15), p=0.004], Pulmonary Artery Systolic Pressure (PASP) [OR 1.02 (1.00;1.04), p=0.05], CVP/ Pulmonary Capillary Wedge Pressure (PCWP) ratio [OR 2.78 (1.14;6.80), p=0.025], Pulmonary Vascular Resistance (PVR) [OR 1.15 (1.01;1.32), p=0.042], Trans-Pulmonary Gradient (TPG) [OR 1.11 (1.03;1.18), p=0.003] and Diastolic Trans-Pulmonary Gradient (DPG) [OR 1.10 (1.02;1.20), p=0.015]. Thereafter, PASP [OR 1.03 (1.00;1.05), p=0.016] and TPG [OR 1.08 (1.01;1.17), p=0.03] did impact negatively on the occurrence of EGF. Preoperative right ventricular dysfunction did not result to influence on follow-up (FU) mortality. On the multivariable analysis, CVP and TPG resulted to be independent predictors of in-hospital mortality while TPG of EGF. By spitting patients population into 4 hemodynamic profiles in terms of pulsatile load, focusing on Pulmonary Artery Compliance (PACi), and right ventricle hemodynamic response to load, focusing on CVP:PCWP ratio, we resulted to have a high PACi/high PVC:PCWP profile with a higher risk of in-hospital mortality [OR 2.40 (1.04;5.54), p=0.05] and EGF [OR 3.40 (1.32;7.28), p= 0.01]. Overall survival at 1, 5 and 10 years was 89.4%, 80.8% and 66.4%, respectively. By analyzing the four hemodynamic profiles, patients with low PACi/high PVC:PCWP showed the worst survival (Log-rank=0.045). In our patients population, CVP and TPG resulted to be independent risk factors of in-hospital mortality while TPG of EGF. Thus, the detection of pre-operative right ventricular dysfunction in potential heart transplant recipients should be managed early and treated properly in terms of preoperative clinical optimization to improve the postoperative outcomes.