Patients with Severe Right Ventricular Dysfunction and Low Arterial Elastance Have Poor Prognosis Even after Heart Transplantation

Abstract

<h3>Purpose</h3> To study the impact of severe right ventricular (RV) dysfunction on survival after heart transplantation <h3>Methods</h3> Data from 250 patients was analyzed for the effect of severe RV dysfunction , categorized by high right atrial pressure (RAP), low pulmonary artery pulsatility index (PAPi) and the presence of ascites, on 90 day and medium term survival . Systemic afterload was estimated by arterial elastance (<i>E_a</i>) (method given below) and systemic vascular resistance (SVR) . <i>Calculation of E_a: End systolic pressure E_sys) = (2* systolic blood pressure + diastolic pressure) / 3 . (1) Stroke volume (SV) = (CO / HR). (2) Arterial Elastance (E_a ) = E_sys / SV (3)</i> Organ perfusion pressure index (OPPI) ((Mean arterial pressure - RAP) / BSA) and modified MELD score was calculated . <h3>Results</h3> 90 day survival was worse with RAP > 15 (p = 0.014 ) , PAPi < 0.9 (p= 0.104) ,with ascites (p = 0.005) <i>,</i> higher MELD score ( odds ratio 1.07, p = 0.06 ) and lower OPPI (odds ratio 0.92,p = 0.004). The effect of RAP ,PAPi and MELD score on mortality was not seen if afterload was higher (<i>Ea > 2.7,SVR >1600 dynes/cm^-5/sec).</i> 5 years survival was worse for RAP > 15 ( p = 0.0059) , ascites (p = 0.009), PAPi < 0.9 (p= 0.1897) and MELD score > 20 ( p=0.022 ) This effect of RAP , PAPi and MELD score was absent if Ea > 2.7. Survival for OPPI < 40 was worse (p = 0.0124) but only if RAP was more than 15 mm hg. The relationship between RAP,Ea and OPPI and the effect on medium term survival is shown in a cox proportional hazard regression survival curve ( Fig 1). <h3>Conclusion</h3> 90 day and 5 year survival after heart transplantation are worse in patients with severe preoperative RV dysfunction but only <i>if the systemic arterial afterload</i> is low . Organ perfusion pressure index less than 40 appears to be deleterious in the short and medium term. Vasodilator drugs used to treat systolic left heart failure may adversely affect survival if RAP is high . Intra aortic balloon pump might be a more physiological alternative in patients awaiting transplantation.