Pretransplant Pulmonary Hypertension Research Articles

Days Alive and Out of the Hospital After Heart Transplantation: A Retrospective Cohort Study

Evaluate days alive and out of the hospital (DAOH) as an outcome measure after orthotopic heart transplantation in patients with mechanical circulatory support (MCS) as a bridge to transplant compared to those patients without prior MCS. A retrospective observational study of adult patients who underwent cardiac transplantation between January 1, 2015, and January 1, 2020. The primary outcome was DAOH at 365 days (DAOH365) after an orthotopic heart transplant. A Poisson regression model was fitted to detect the association between independent variables and DAOH365. An academic tertiary referral center. A total of 235 heart transplant patients were included-103 MCS as a bridge to transplant patients, and 132 direct orthotopic heart transplants without prior MCS. The median DAOH365 for the entire cohort was 348 days (IQR 335.0-354.0). There was no difference in DAOH365 between the MCS patients and patients without MCS (347.0 days [IQR 336.0-353.0] v 348.0 days [IQR 334.0-354.0], p=0.43). Multivariate analysis identified patients who underwent a transplant after the 2018 heart transplant allocation change, pretransplant pulmonary hypertension, and increased total ischemic time as predictors of reduced DAOH365. In this analysis of patients undergoing orthotopic heart transplantation, there was no significant difference in DAOH365 in patients with prior MCS as a bridge to transplant compared to those without MCS. Incorporating days alive and out of the hospital into the pre-transplant evaluation may improve understanding and conceptualization of the post-transplantation patient experience and aid in shared decision-making with clinicians.

Impact of lung transplantation on diastolic dysfunction in recipients with pretransplant pulmonary hypertension

ObjectivePulmonary hypertension can cause left ventricular diastolic dysfunction through ventricular interdependence. Moreover, diastolic dysfunction has been linked to adverse outcomes after lung transplant. The impact of lung transplant on diastolic dysfunction in recipients with pretransplant pulmonary hypertension is not defined. In this cohort, we aimed to assess the prevalence of diastolic dysfunction, the change in diastolic dysfunction after lung transplant, and the impact of diastolic dysfunction on lung transplant outcomes. MethodsIn a large, single-center database from January 2011 to September 2021, single or bilateral lung transplant recipients with pulmonary hypertension (mean pulmonary artery pressure > 20 mm Hg) were retrospectively identified. Those without a pre- or post-transplant echocardiogram within 1 year were excluded. Diastolic dysfunction was diagnosed and graded according to the American Society of Echocardiography 2016 guideline on assessment of diastolic dysfunction (present, absent, indeterminate). McNemar's test was used to examine association between diastolic dysfunction pre- and post-transplant. Kaplan–Meier and Cox regression analysis were used to assess associations between pre–lung transplant diastolic dysfunction and post–lung transplant 1-year outcomes, including mortality, major adverse cardiac events, and bronchiolitis obliterans syndrome grade 1 or higher–free survival. ResultsOf 476 primary lung transplant recipients, 205 with pulmonary hypertension formed the study cohort (mean age, 56.6 ± 11.9 years, men 61.5%, mean pulmonary artery pressure 30.5 ± 9.8 mm Hg, left ventricular ejection fraction < 55% 9 [4.3%]). Pretransplant, diastolic dysfunction was present in 93 patients (45.4%) (grade I = 8, II = 84, III = 1), absent in 16 patients (7.8%), and indeterminate in 89 patients (43.4%), and 7 patients (3.4%) had missing data. Post-transplant, diastolic dysfunction was present in 7 patients (3.4%) (grade I = 2, II = 5, III = 0), absent in 164 patients (80.0%), and indeterminate in 15 patients (7.3%), and 19 patients (9.3%) had missing data. For those with diastolic dysfunction grades in both time periods (n = 180), there was a significant decrease in diastolic dysfunction post-transplant (148/169 patients with resolved diastolic dysfunction; McNemar's test P < .001). Pretransplant diastolic dysfunction was not associated with major adverse cardiac events (hazard ratio [HR], 1.08, 95% CI, 0.72-1.62; P = .71), bronchiolitis obliterans syndrome–free survival (HR, 0.67, 95% CI, 0.39-1.56; P = .15), or mortality (HR, 0.70, 95% CI, 0.33-1.46; P = .34) at 1 year. ConclusionsDiastolic dysfunction is highly prevalent in lung transplant candidates with normal left ventricular systolic function and pulmonary hypertension, and resolves in most patients after lung transplant regardless of patient characteristics. Pre–lung transplant diastolic dysfunction was not associated with adverse lung or cardiac outcomes after lung transplant. Collectively, these findings suggest that the presence of diastolic dysfunction in lung transplant recipients with pulmonary hypertension has no prognostic significance, and as such diastolic dysfunction and the associated clinical syndrome of heart failure with preserved ejection fraction should not be considered a relative contraindication to lung transplant in such patients.

Percutaneous left ventricular assist device as a short-term mechanical circulatory support before heart transplantation in patients with high pre-transplant pulmonary hypertension (series of clinical cases)

Federation In certain categories of patients with end-stage heart failure (HF), short-term mechanical circulatory support (MSC) is successfully used as a mechanical «bridge» to heart transplantation (HTx). In predominantly left-ventricular (LV) dysfunction, the use of isolated coronary artery bypass, especially amidst high pulmonary hypertension (PH), seems to be a more physiological method of short-term MSC.Objective: to present the results of a series of clinical cases of the use of percutaneous left ventricular assist device (pLVAD) before HTx in potential recipients with predominantly LV dysfunction and concomitant high PH.Materials and methods. Three potential heart recipients with predominantly left-sided HF and high pre-transplant PH (pulmonary vascular resistance, PVR, 4.7–6.6 Wood units) who required MSC due to progression of hemodynamic disorders were included in the study. A standard venous extracorporeal membrane oxygenation (ECMO) cannula (26 F) was used for percutaneous left atrial-femoral artery (LA–FA) bypass. The cannula was passed from the transfemoral route through the interatrial septum into the left atrial cavity. A paracorporeal centrifugal pump provided blood injection through a standard arterial ECMO cannula (15 F).Results. pLVAD unloaded the left ventricle effectively (PCWP reduced from 27–32 to 15–20 mmHg), reduced pre-transplant PH (mean pulmonary artery pressure (mPAP) reduced from 45–53 to 28–33 mmHg) and improved systemic hemodynamics (cardiac index (CI) increased from 1.8–1.9 to 2.1–2.6 l/min/m2 and mean arterial pressure (mAP) from 56–59 to 70–75 mmHg). All these created the prerequisites for subsequent successful HTx. Against the background of pLVAD, transpulmonary pressure gradient (TPG) decreased from 15–25 to 13–15 mmHg, and PVR decreased from 4.7–6.6 to 2.7–3.4 Wood units. pLVAD flow rate was 2.9–3.8 L/min or 1.38–1.83 L/min/m2 at 4700–7100 rpm. pLVAD duration ranged from 4 (n = 1) to 7 (n = 2) days. All patients underwent successful HTx.Conclusion. pLVAD is a highly effective method of short-term MSC in potential recipients with predominantly LV dysfunction and concomitant high PH, leading to rapid regression of the dysfunction against the background of left ventricular unloading. This short-term MSC technique can be successfully realized using standard ECMO cannulas and centrifugal pumps of any modification, without requiring additional special equipment.

Incidence, Clinical Correlates, and Outcomes of Pulmonary Hypertension After Kidney Transplantation: Analysis of Linked US Registry and Medicare Billing Claims.

The incidence, risks, and outcomes associated with pulmonary hypertension (P-HTN) in the kidney transplant (KTx) population are not well described. We linked US transplant registry data with Medicare claims (2006-2016) to investigate P-HTN diagnoses among Medicare-insured KTx recipients (N = 35 512) using billing claims. Cox regression was applied to identify independent correlates and outcomes of P-HTN (adjusted hazard ratio [aHR] 95%LCLaHR95%UCL) and to examine P-HTN diagnoses as time-dependent mortality predictors. Overall, 8.2% of recipients had a diagnostic code for P-HTN within 2 y preceding transplant. By 3 y posttransplant, P-HTN was diagnosed in 10.310.6%11.0 of the study cohort. After adjustment, posttransplant P-HTN was more likely in KTx recipients who were older (age ≥60 versus 18-30 y a HR, 1.912.403.01) or female (aHR, 1.151.241.34), who had pretransplant P-HTN (aHR, 4.384.795.24), coronary artery disease (aHR, 1.051.151.27), valvular heart disease (aHR, 1.221.321.43), peripheral vascular disease (aHR, 1.051.181.33), chronic pulmonary disease (aHR, 1.201.311.43), obstructive sleep apnea (aHR, 1.151.281.43), longer dialysis duration, pretransplant hemodialysis (aHR, 1.171.371.59), or who underwent transplant in the more recent era (2012-2016 versus 2006-2011: aHR, 1.291.391.51). Posttransplant P-HTN was associated with >2.5-fold increased risk of mortality (aHR, 2.572.843.14) and all-cause graft failure (aHR, 2.422.642.88) within 3 y posttransplant. Outcome associations of newly diagnosed posttransplant P-HTN were similar. Posttransplant P-HTN is diagnosed in 1 in 10 KTx recipients and is associated with an increased risk of death and graft failure. Future research is needed to refine diagnostic, classification, and management strategies to improve outcomes in KTx recipients who develop P-HTN.

Effect of pulmonary hypertension on 5-year outcome of kidney transplantation.

Pulmonary hypertension affects about one in four patients with advanced chronic kidney disease and significantly increases the risk of death. Kidney transplantation is the recommended management option for patients with progressive or end‐stage kidney disease. However, the resource‐limited nature of kidney transplantation and its intensive peri‐operative and posttransplantation management motivates careful consideration of potential candidates’ medical conditions to optimally utilize available graft organs. Since pulmonary hypertension is known to increase peri‐operative morbidity and mortality among patients living with chronic kidney disease, we performed a retrospective cohort study to assess the impact of pretransplantation pulmonary hypertension on posttransplantation outcome. All patients who underwent single‐organ kidney transplantation at our center in calendar years 2010 and 2011 were identified and the presence of pulmonary hypertension was determined from pretransplantation echocardiography. Outcome was assessed at 5 years following kidney transplantation. Of 350 patients who were included, 117 (33%) had evidence of pulmonary hypertension. The risk of death, graft dysfunction, or graft failure at 5 years after kidney transplantation was higher among those with pulmonary hypertension, primarily owing to an increased risk of graft dysfunction. Importantly, in this institutional cohort of kidney transplant recipients, pretransplant pulmonary hypertension was not associated with a difference in posttransplant survival at 5 years. While institutional and regional differences in outcome can be expected, this report suggests that carefully selected patients with pulmonary hypertension receive similar long‐term benefits from kidney transplantation.

The echocardiographic course of pretransplant pulmonary hypertension following kidney transplantation and associated outcomes

The post 3 kidney transplant course of pretransplant echocardiographically‐defined pulmonary hypertension (PH) was reviewed in 115 patients. Of these 61 patients (the largest cohort reported to date), underwent 160 “for indication” echocardiograms posttransplant (mean echocardiograms per patient: 2.6 ± 2.3). Patients undergoing posttransplant echocardiograms demonstrated greater risks for worse outcomes than those without posttransplant echocardiograms; however, there was no difference in mortality, death‐censored graft failure or the composite of death or graft failure between these two groups. Of patients tested, 36 (59%) showed resolution of PH at a median of 37.5 months. Six patients (16.7%) in whom PH resolved (at a median of 29 months), experienced recurrence of PH after an interval of 48 months. No pretransplant demographic or echocardiographic characteristics distinguished those in whom PH persisted versus resolved. Though there was no difference in the risk for mortality or death‐censored graft loss between the two groups at 3 and 5 years, there was a higher risk for the composite of mortality or graft loss at three but not at five years in the group with persistent PH. In conclusion, echocardiographically defined PH resolved in 59% of patients following kidney transplantation; but irrespective of resolution there was no clear association with worse outcome.

Kidney Transplantation Confers Survival Benefit for Candidates With Pulmonary Hypertension.

Using UR Renal Data System (2000-2018), we studied 90 819 adult KT recipients. Delayed graft function, death-censored graft failure, and mortality were compared between recipients with and without PtPH using inverse probability weighted logistic and Cox regression. Survival benefit of KT was determined using stochastic matching and stabilized inverse probability treatment Cox regression. Among 90 819 KT recipients, 2641 (2.9%) had PtPH. PtPH was associated with higher risk of delayed graft function (odds ratio, 1.23; 95% CI, 1.10-1.36; P < 0.01), death-censored graft failure (hazard ratio [HR], 1.23; 95% CI, 1.11-1.38; P < 0.01), and mortality (HR, 1.56; 95% CI, 1.44-1.69; P < 0.01). However, patients with PtPH who received a KT had a 46% reduction in mortality (HR, 0.54; 95% CI, 0.48-0.61; P < 0.01) compared with those who remained on the waitlist. Although PtPH is associated with inferior post-KT outcomes, KT is associated with better survival compared with remaining on the waitlist. Therefore, KT is a viable treatment modality for appropriately selected patients with PtPH.

Clinical impact of pre-kidney transplant pulmonary hypertension on post-transplant outcomes.

Outcomes of kidney transplant (KT) patients with pre-transplant pulmonary hypertension (PH) are poorly understood. PH patients are often considered high risk and excluded from KT. We investigated the association of pre-transplant PH with KT recipient's outcomes. A single-center, retrospective study that reviewed all patients transplanted from 2010 to 2016, who had a transthoracic echocardiogram (TTE) before KT and at least one TTE post-KT. The TTE closest to the KT was used for analyses. PH is defined as pulmonary artery systolic pressure (PASP) ≥ 40mm Hg. Of 204 patients, 61 had PASP ≥ 40mm Hg (with PH) and 143 had PASP < 40mm Hg (without PH) prior to KT. No statistically significant differences existed between the two groups in baseline demographics, renal failure etiologies, dialysis access type, and cardiovascular risk factors. The mean difference in pre-KT PASP was 18.1 ± 7mm Hg (P < 0.001). Patients with PH had a statistically significant decrease in PASP post-KT compared to the patients without PH with a mean change of -7.03 ± 12.28mm Hg vs. + 3.96 ± 11.98mm Hg (p < 0.001), respectively. Moderate mitral and moderate-severe tricuspid regurgitation were the only factors found to be independently associated with PH (p = 0.001) on multivariable analysis. No statistically significant difference was notable in patient survival, graft function, and creatinine post-KT in both groups. PH pre-KT particularly mild-moderate PH did not adversely affect intermediate (90-day) and long-term allograft and patient survival. Patients with mild-moderate PH should not be excluded from KT.

The Association of Pretransplant Pulmonary Hypertension With Patient and Graft Survival After Kidney Transplantation: A Retrospective Cohort Study

BackgroundPulmonary hypertension (PH) has been well characterized in end-stage kidney disease and carries a grave prognosis. Its relationship to kidney transplantation outcomes is uncertain. The purpose of the present study was to characterize PH in kidney transplant candidates and to evaluate the relationship of PH to post-transplantation outcomes. MethodsA retrospective review of medical records and echocardiographic findings in all patients listed and transplanted at a large urban academic medical center from 2010 to 2015 was undertaken. PH (defined as echocardiographic evidence of pulmonary artery systolic pressure ≥ 35 mm Hg) was assessed along with demographics, and comorbidities for its relationship to patient, and graft survival by univariable and multivariable analysis. ResultsOf 733 patients, 15.6% (115) had PH. PH in this population was primarily due to left ventricular (LV) diastolic dysfunction. Patient survival (78.3% vs 89.6%, P = .02) and the composite of patient and graft survival (70.7% vs 85.0%, P = .04) was reduced at 5 years in patients with PH as compared to patients with No PH, respectively. However, multivariable analysis suggested that age at presentation, race, and left ventricular systolic function but not PH were significantly associated with patient mortality or graft loss. ConclusionReduced patient and graft survival seen in patients with pulmonary hypertension appears to be related to risk factors other than the pulmonary hypertension itself; therefore, pretransplant PH should not be considered as a barrier to kidney transplantation.

Bronchoscopic Interventions as a Management of Airway Complications After Lung Transplant Including Assessment of Risk Factors With Special Consideration for Pretransplant Pulmonary Hypertension

BackgroundLung transplant (LTx) is a procedure associated with risk of complications related to airway stenosis that can be treated with bronchoscopic interventions (BIs). The aim of the study was to assess the frequency and risk factors associated with increased need of bronchial interventions in the post-transplant period. MethodsThe retrospective study reviewed cases of 165 patients (63 women) who underwent LTx from April 2013 to June 2019. For dichotomous discrete variables (occurrence or lack of intervention) multivariate logistic regression analysis was performed to assess the aforementioned risk factors. ResultsBIs were required among 38.55% of lung recipients (n = 65). The number of interventions/patient/y decreases between years 1 and 2 (P < .001), 2 and 3 (P = .013), and 3 and 4 (P < .001); after the fourth year post LTx the differences are not statistically significant. Each 1 mm Hg above 25 mm Hg of mean pulmonary arterial pressure causes statistically significant elevation in the number of interventions by 0.7% in the first year after the procedure. The number of BIs per patient among lung recipients who received a transplant because of idiopathic pulmonary arterial hypertension was statistically significantly higher compared with patients with another underlying lung disease. ConclusionsAirway complications developed in the post-transplant period caused a significant number of patients to be in need of BI, especially balloon bronchoplasty. The highest number of interventions occurred within the first year after LTx, and BI decreases over time. Mean pulmonary arterial pressure measured during qualification may have the ability to predict whether the patient would require BI after LTx.

Impact of Severe Pulmonary Hypertension on Right Heart Hemodynamics and Outcomes Following Cardiac Transplantation: A Single Center Experience

The prognostic impact of pulmonary hypertension (PH) is debated as well as the trend of pulmonary hemodynamic variables after heart transplantation (HTx). We investigated the impact of preoperative PH on postoperative survival and on the evolution of right heart hemodynamics (RHH) after HTx. We reviewed the records of 431 consecutive HTx recipients, divided in a non-PH group (270 pts) and a PH group (161 pts).PH was defined as pulmonary vascular resistance ≥2.5 Wood units (WU) at right heat catheterization: mild (97 pts; PVR: 2.5-3.4WU), moderate (41 pts; PVR: 3.5-4.9WU) and severe PH (23 pts; PVR ≥5.0WU). RHH [systolic/mean/diastolic pulmonary artery-systolic-pressure (PAP), pulmonary-capillary-wedge-pressure (PCWP), transpulmonary gradient (TPG), cardiac output (CO), pulmonary vascular resistance (PVR), pulmonary-arterial-pulsatility-index (PAPi) and right-ventricle-stroke-work-index (RVSWI)] were measured before HTX and 3, 6, 12 months, 3, 5 years after HTX. Survival analysis was conducted using Kaplan-Meier curves. Preoperatively, patients with severe PH had significantly (P<0.001) higher mean PAP (64.5/42.2/28.8 vs. 48.6/32.6/21.8mmHg), TPG (16.8 vs. 9.9mmHg), PVR (6.1 vs. 3.2WU) and RVSWI (568.4 vs. 428.9) than patients with mild/moderate PH. After HTx, the PH-group had a higher incidence of graft dysfunction (20.5 vs. 14.8%;P=0.01), right ventricular failure (9.3 vs. 4.8%;P=0.03), ECMO (10 vs. 5.1%;P=0.01), ICU stay (8.4 vs. 6.8 day;P=0.02) than non-PH patients. In hospital mortality was 10.6% in PH-patients (15.8% vs. 9.9% in severe vs. mild/moderate PH;P=0.04) vs. 6.3% in non-PH group (P=0.01). Ten-years survival rates were 70% in PH-patients (71% in severe PH) vs. 72% in non-PH patients. RHH improved early after HTx, without significant differences between severe PH and mild/moderate PH [PAP (30.1/19.4/10.9 vs. 26.8/17.3/9.8mmHg), TPG (10.9 vs. 8.5mmHg), PVR (1.8 vs. 1.5WU) and RVSWI (506.1 vs. 470.9) but slightly worsened after 3-5 years. Pre-transplant PH is an independent predictor of early mortality after HTx, not affecting long-term survival even when severe. After an early significant improvement of RHH, mean PAP, TPG and PVR increase while CO, PAPi and RVSWI decrease during follow-up. A rigorous monitoring of RHH must be scheduled during FU.

Donor-Recipient Predicted Heart Mass Ratio as Predictor of Right Ventricular-Pulmonary Arterial Coupling Post Heart Transplantation

Background Right ventricular dysfunction is a frequent complication after heart transplantation. Right ventricular-pulmonary arterial (RV-PA) coupling interactions negatively impact right ventricular function and have prognostic implications in heart failure; yet, the temporal profile of RV-PA interactions in the context of heart transplantation has not been explored, particularly its relationship with donor-recipient size matching. Our aim was to assess RV-PA coupling at seven and 30 days after heart transplantation and to study its association with donor-recipient size matching. Methods Clinical, echocardiographic and hemodynamic data from a retrospective cohort of consecutive adult heart transplant recipients and their respective donors were reviewed. Coupling between RV-PA was examined by the ratio between right ventricular fractional area change and pulmonary artery systolic pressure (RVFAC/PASP) at seven and 30 days post-transplant. Donor-recipient size matching was assessed by donor-recipient predicted heart mass (PHM) ratio, and appropriate size graft was defined as PHM ratio ≥1. Predictors of RV-PA coupling were examined by multiple linear regression analysis. Results Thirty-four patients transplanted between July/2015 and June/2018 were included (48 ± 15 years, 50% male). Fifty percent had pre-transplant pulmonary hypertension (mean pulmonary artery pressure 25.71 ± 7.12 mmHg). Median PHM ratio was 1.08 (p25-75: 0.94-1.29), and 40% grafts were considered undersized. Post-transplant RV-PA coupling was decreased and improved from seven to 30 days (RVFAC/PASP 0.98 ± 0.24 vs. 1.26 ± 0.27; p Conclusions These findings suggest the impact of PHM on RV-PA coupling interactions and, subsequently, in right ventricular dysfunction post heart transplantation. This highlights the role of PHM ratio as a metric to improve donor selection.

Incidence of Right Ventricular Dysfunction in Adult Patients Submitted to Heart Transplantation According to the Presence of Pre-Transplant Pulmonary Hypertension

Purpose: Introduction Pre-transplant irreversible pulmonary hypertension (PH) is a contraindication to heart transplantation (HTx) due to the high risk of post-transplant right ventricular (RV) dysfunction. When ventricular assist devices (VAD) are not available, HTx may be considered in selected patients PH. Objective To evaluate the incidence of right ventricular dysfunction in patients with reversible PH compared to patients with no PH submitted to HT. Methods We performed a retrospective analysis of all HTx performed from Jan-13 to Oct-17 at Heart Institute using RedCap database. PH was defined according to the presence of at least one of the following criteria at baseline: pulmonary systolic artery pressure (PSAP) > 50mmHg or pulmonary vascular resistance (PVR) >5uW or transpulmonary gradient (TPG) >15. Patients with PVR below 5uW at baseline or after the reversibility test were submitted to HTx. Early RV and LV dysfunctions and 30-day mortality were evaluated in patients with and without PH. Diastolic pulmonary gradient (DPG) was also evaluated in this cohort. Results 200 patients were submitted to HTx, 126(63%) were male, 127(63.5%) self-declared white, and with average age of 46.3±12.2 years-old. Of these patients, 180 had underwent to pre-transplant right heart catheterization. Considering criteria described above, 87(48.3%) patients had PH and were compared to patients with no PH (n=93,51.7%). Moderate/severe RV dysfunction was present in 16(18.8%) patients in PH group and 10(11.1%) patients in no HP group (p=0.152). There was also no difference in LV dysfunction (p=0.621) or 30-day mortality (p=0.534) between groups. All RV catheterization measures were higher in PH group (p Conclusion In our cohort, the incidence of RV as well as LV dysfunction and 30-day mortality were similar in patients with and without PH. In a population where VAD is not available, HTx could be an alternative to patients with PH, especially if DPG is low. Larger prospective studies should be performed to test the role of DPG in patient evaluation to HTx.

(601) - Impact of Pre-Transplant Pulmonary Hypertension Grading on Early- to Long-Term Hemodynamics, Right Venticular Graft Function and Survival After Heart Transplantation

(601) - Impact of Pre-Transplant Pulmonary Hypertension Grading on Early- to Long-Term Hemodynamics, Right Venticular Graft Function and Survival After Heart Transplantation

Dilemma in accepting ESRD patients with pulmonary hypertension for renal transplantation: Our experience

Pulmonary hypertension (PH) has been well characterized in end-stage kidney disease and carries a grave prognosis. Its relationship to kidney transplantation outcomes is uncertain. The purpose of the present study was to characterize PH in kidney transplant candidates and to evaluate the relationship of PH to post-transplantation outcomes.A retrospective review of medical records and echocardiographic findings in all patients listed and transplanted at a large urban academic medical center from 2010 to 2015 was undertaken. PH (defined as echocardiographic evidence of pulmonary artery systolic pressure ≥ 35 mm Hg) was assessed along with demographics, and comorbidities for its relationship to patient, and graft survival by univariable and multivariable analysis.Of 733 patients, 15.6% (115) had PH. PH in this population was primarily due to left ventricular (LV) diastolic dysfunction. Patient survival (78.3% vs 89.6%, P = .02) and the composite of patient and graft survival (70.7% vs 85.0%, P = .04) was reduced at 5 years in patients with PH as compared to patients with No PH, respectively. However, multivariable analysis suggested that age at presentation, race, and left ventricular systolic function but not PH were significantly associated with patient mortality or graft loss.Reduced patient and graft survival seen in patients with pulmonary hypertension appears to be related to risk factors other than the pulmonary hypertension itself; therefore, pretransplant PH should not be considered as a barrier to kidney transplantation.

Trends and outcomes of patients with adult congenital heart disease and pulmonary hypertension listed for orthotopic heart transplantation in the United States

Heart transplantation is increasing in patients with adult congenital heart disease (ACHD). In this population, the association of pulmonary hypertension (PH) with post-transplant outcomes is not well-defined. Using data from the United Network for Organ Sharing database (1987 to 2014), we identified ACHD patients listed for heart transplantation, and examined survival between those with and without PH (pre-transplant PH defined as transpulmonary pressure gradient >12 mm Hg). Among 983 ACHD patients, 216 (22%) had PH. At time of listing, PH patients had a transpulmonary pressure gradient of 17.0 mm Hg vs 6.0 mm Hg (p < 0.01) in the no-PH group. Although left ventricular assist device (LVAD) use was infrequent, 3.1% of PH patients were treated with an LVAD versus 6.8% of the no-PH patients. Days from listing to transplant, days from listing to death on the waitlist and length of post-transplant hospitalization were not significantly different between the PH and no-PH groups. However, PH was associated with higher waitlist mortality (HR 1.73, CI 1.25 to 2.41). Pre-transplant PH was not associated with post-transplant mortality at 30 days (HR 0.51, CI 0.23 to 1.13), 1 year (HR 0.68, 95% CI 0.40 to 1.18) or 5 years (HR 0.84, 95% CI 0.55 to 1.29). PH is common among ACHD patients listed for transplant and is associated with increased waitlist mortality. Conversely, PH was not associated with worse survival after transplant. Bridge-to-transplant LVAD therapy was uncommon in this ACHD population.

Impact of pre-transplant pulmonary hypertension on survival after heart transplantation: A UNOS registry analysis

IntroductionSevere pre-transplant pulmonary hypertension (PH) has been associated with adverse short-term clinical outcomes after heart transplantation in relatively small single-center studies. The impact of pre-transplant PH on long-term survival after heart transplantation has not been examined in a large, multi-center cohort. MethodsAdults (≥18years) who underwent first time heart transplantation in the United States between 1987 and 2012 were retrospectively identified from the United Network for Organ Sharing registry. Pre-transplant PH was classified as mild, moderate, or severe based on pulmonary vascular resistance (PVR), trans-pulmonary gradient (TPG), and pulmonary artery (PA) mean pressure. Primary outcome was all-cause mortality. ResultsData from 26,649 heart transplant recipients (mean age 52±12years; 76% male; 76% Caucasian) were analyzed. During a mean follow-up of 5.7±4.8years, there were 10,334 (39%) deaths. Pre-transplant PH (PVR≥2.5WU) was a significant predictor of mortality (hazard ratio 1.10, 95% confidence interval 1.05–1.14, p<0.0001) in multivariable analysis. However, the severity of pre-transplant PH (mild/moderate vs. severe) did not affect short or long-term survival. Similarly, even in patients who were supported with either a left ventricular assist device or a total artificial heart prior to transplant, severe pre-transplant PH was not associated with worse survival when compared to patients with mild/moderate pre-transplant PH. ConclusionPre-transplant PH (PVR≥2.5WU) is associated with a modest increase in mortality when compared to patients without pre-transplant PH. However, the severity of pre-transplant PH, assessed by PVR, TPG, or mean PA pressure, is not a discriminating factor for poor survival in patients listed for heart transplantation.

Severe Pre-Transplant Pulmonary Hypertension Is Not Associated with Detrimental Long-Term Survival after Heart Transplantation: Analyses from the UNOS Registry

Severe Pre-Transplant Pulmonary Hypertension Is Not Associated with Detrimental Long-Term Survival after Heart Transplantation: Analyses from the UNOS Registry

Potential functional and survival benefit of double over single lung transplantation for selected patients with idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a frequent indication for lung transplantation (LTX) with pulmonary hypertension (PH) negatively affecting outcome. The optimal procedure type remains a debated topic. The aim of this study was to evaluate the impact of pretransplant PH in IPF patients. Single LTX (SLTX, n = 46) was the standard procedure type. Double LTX (DLTX, n = 30) was only performed in cases of relevant PH or additional suppurative lung disease. There was no significant difference for pretransplant clinical parameters. Preoperative mean pulmonary arterial pressure was significantly higher in DLTX recipients (22.7 +/- 0.8 mmHg vs. 35.9 +/- 1.8 mmHg, P < 0.001). After transplantation, 6-min-walk distance and BEST-FEV(1) were significantly higher for DLTX patients (6-MWD: 410 +/- 25 m vs. 498 +/- 23 m, P = 0.02; BEST-FEV(1): 71.2 +/- 3.0 (% pred) vs. 86.2 +/- 4.2 (% pred), P = 0.004). Double LTX recipients demonstrated a significantly better 1-year-, overall- and Bronchiolitis obliterans Syndrome (BOS)-free survival (P < 0.05). Cox regression analysis confirmed SLTX to be a significant predictor for death and BOS. Single LTX offers acceptable survival rates for IPF patients. Double LTX provides a significant benefit in selected recipients. Our data warrant further trials of SLTX versus DLTX stratifying for potential confounders including PH.

60: Impact of Pre-Transplant Pulmonary Hypertension on Post-Transplant Outcomes in IPF

60: Impact of Pre-Transplant Pulmonary Hypertension on Post-Transplant Outcomes in IPF