Outcomes Associated with Early Post-Heart Transplant Restrictive Hemodynamics

Abstract

<h3>Purpose</h3> The implications of the development of restrictive hemodynamics (RH) in the absence of overt graft dysfunction post heart transplantation (OHT) are unclear. We sought to determine the incidence of patients with post-OHT RH profiles and the respective clinical outcomes associated with this pathophysiologic state. <h3>Methods</h3> We retrospectively analyzed 164 (2008-2020) patients who underwent OHT at our institution. Hemodynamics were obtained during scheduled endomyocardial biopsies. Right atrial pressure ≥ 12, pulmonary capillary wedge pressure > 15, and cardiac index > 2.2 L/min/m2 in the absence of graft dysfunction by echocardiography and without evidence of rejection met criteria for a RH profile. We sought to identify if RH profiles persisted at 12 months in addition to rate of heart failure admissions, change in renal function (glomerular filtration rate, GFR), and calcineurin inhibitor protocol deviation (decreases in dosing) compared to controls who did not have primary graft dysfunction or abnormal hemodynamics. <h3>Results</h3> Of 164 patients, 39 had RH profiles at week 4. There was an increased risk of heart failure admissions in those with RH profiles (incident rate ratio 1.81, 95% CI 1.78-1.85, P<0.001) (Panel A). The weekly diuretic dose at 9 months in the RH group was 308 mg/week compared to 127 mg/week in controls (P=0.005) (Panel B). Lower GFR was observed in those with RH at 4 weeks compared to controls, though no significant decline in GFR was observed longitudinally (Panel C). Calcineurin inhibitor protocol deviation occurred in 15 of 39 patients with RH and in 23 of 125 patients without RH (P=0.02). RH persisted at one year in 25.6% of patients (10/39). <h3>Conclusion</h3> Post-OHT patients who develop a RH profile are more likely to experience heart failure hospitalizations, decreases in calcineurin-inhibitor dosing, and have higher loop diuretic doses. The majority tend to normalize their hemodynamic profile at 1 year. Further studies are required to elucidate what factors contribute to the development of this phenotype.