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Outcomes in patients with low left ventricular ejection fraction after heart transplantation
Branislav Radovancevic1, Rajko Radovancevic, Bojan Vrtovec
1Cardiopulmonary Transplantation Service, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, TX 77225-0345, USA. bradovancevic@heart.thi.tmc.edu
Insights
Low ejection fraction (EF) after heart transplantation (HT) is not always an ominous sign. Later onset low EF, particularly prolonged episodes, is associated with better survival and less rejection, not indicating repeat HT.
Area of Science:
- Cardiology
- Transplantation Medicine
- Immunology
Background:
- Low left ventricular ejection fraction (EF) following heart transplantation (HT) is historically viewed as a negative prognostic indicator.
- Identifying patients who may benefit from immediate retransplantation is crucial for improving outcomes.
Purpose of the Study:
- To evaluate the outcomes of patients experiencing low EF after HT.
- To determine if specific patient subsets with low EF could benefit from prompt retransplantation.
Main Methods:
- A retrospective review of 825 heart transplant recipients was conducted.
- Eighty-one patients with low EF (<35%) were analyzed for survival, duration of low EF episodes, rejection, infection, and transplant coronary artery disease (CAD).
Main Results:
- Low EF developed on average 800 days post-HT and lasted 550 days. Actuarial survival was 46% at 5 years.
- Prolonged low EF episodes (>2 years) had a later onset (1341 days vs. 656 days) and were associated with longer survival (2247 days vs. 1266 days) and lower rejection rates (6% vs. 26%).
- Infection and transplant CAD incidence did not significantly differ between prolonged and shorter low EF groups.
Conclusions:
- Low EF after HT, especially with later onset, does not correlate with poor survival or significant rejection.
- The presence of low EF, even with transplant coronary artery disease (CAD), is not an independent indication for repeat heart transplantation.
Objectives:
Low left ventricular ejection fraction (EF) after heart transplantation (HT) is considered an ominous sign. We reviewed our database in order to determine outcomes in patients with low EF after HT and to identify a subset of patients who would benefit from immediate retransplantation.
Methods:
We identified 825 patients who underwent HT at our institution between December 1983 and July 1999. Of these, 81 patients (70 men, 11 women; age, 48+/-12 years) had low (<35%) EF as determined by radionuclide ventriculography. Post-transplantation survival; duration of low-EF episodes (>2 years vs. <2 years); and incidence of transplant rejection, infection, and transplant coronary artery disease (CAD) were determined for these patients.
Results:
On average, low EF developed 800+/-1029 days after HT and lasted 550+/-756 days until improvement, repeat HT, or death of the patient. Actuarial survival was 79% at 1 year, 55% at 3 years, and 46% at 5 years. Shorter (<2-year) episodes of low EF tended to have an earlier onset than prolonged (>2-year) episodes (656 days vs. 1341 days) (P=0.014). Patients with prolonged episodes (n=17) survived longer than patients with shorter episodes (n=64) (2247 days vs. 1266 days) (P=0.002). The incidence of hemodynamically significant rejection was lower in the prolonged low-EF group (6% [1/17] vs. 26% [17/64]) (P=0.03). The incidence of infection (31% vs. 53%) and incidence of transplant CAD (47% vs. 39%) did not differ significantly between the prolonged and shorter low-EF groups.
Conclusions:
Low EF after HT, especially with later onset, is not associated with poor survival and is not related to hemodynamically significant rejection. These data further indicate that the presence of low EF even in the setting of CAD is not by itself an indication for repeat HT.