Secular Trends and Outcome of Isolated versus Combined Type 2 Pulmonary Hypertension in Patients with End-Stage Heart Failure

Abstract

Purpose The presence of pulmonary hypertension (PH) is associated with some adverse outcomes following cardiac transplantation (CTx). It is now suggested to diagnose group 2 PH when the mean pulmonary artery pressure (PAPm) is >20 mmHg. The characteristics and outcomes of patients with isolated post-capillary PH (Ipc-PH) versus combined pre- and post-capillary PH (Cpc-PH) diagnosed pre-CTx using this new definition and follow-up long-term after CTx have not been investigated. Methods This study included 361 patients who received a first CTx at the Montreal Heart Institute between January 1983 and December 2014. Patients were classified as having PH based on the most recent right heart catheterization prior to CTx. Ipc-PH was defined by a pulmonary capillary wedge pressure (PCWP) >15 mmHg, PAPm >20 mmHg and pulmonary vascular resistance (PVR) ≤3 woods units, while Cpc-PH was defined by a PCWP >15 mmHg, PAPm >20 mmHg and PVR >3 woods units. Severe PH was defined as PAPm ≥35 mmHg. The cohort was analyzed in 2 groups according to the era of CTx (first: 1983 to 1998; second: 1999 to 2014). The primary outcome was all cause and cardiovascular mortality. The secondary outcomes included a selection of major adverse cardiac events. Results The prevalence of PH was 90.71% in the first era (Ipc-PH=55.19% and Cpc-PH=35.52%) versus 83.71% in the second era (Ipc-PH=49.44% and Cpc-PH=34.27%); P=NS. Both severe Cpc-PH and severe Ipc-PH were less prevalent in the second era (20.22% vs 30.05% Cpc-PH and 16.29% vs 25.14% Ipc-PH; P=0.0016). However, there were no significant changes in PAPm values for all severity of Ipc-PH or Cpc-PH across the eras. The diagnosis of Ipc-PH or Cpc-PH yielded no impact on intra-hospital or 30 days mortality regardless of era of CTx. However, severe PH (severe Ipc-PH or Cpc-PH combined) was associated with an increased 30 days, 1 year and 3 years mortality (all P Conclusion The prevalence of Ipc-PH or Cpc-PH is very high pre-CTx. Unless severe, the presence of group 2-PH has not modulated the early or late post-CTx mortality over 30 years. Accurate diagnosis and better treatments for severe PH pre-CTx are needed to improve outcome in these high-risk patients.