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Published on: August 2, 2019
Clinical and exercise test determinants of survival after cardiac transplantation
Jonathan Myers1, Odd Geiran, Svein Simonsen
1Cardiology Division, Veterans Affairs Health Care System, Palo Alto, CA 94304, USA.
Insights
Long-term survival after cardiac transplantation (CTX) is high, but standard clinical and exercise factors are poor predictors of mortality. Elevated hemodynamic pressures may weakly predict long-term survival in CTX patients.
Area of Science:
- Cardiology
- Transplantation Medicine
- Pulmonary Hypertension
Background:
- Cardiac transplantation (CTX) is a vital treatment for end-stage heart failure.
- A significant gap exists between donor heart availability and patient demand.
- Predicting prognosis post-CTX is crucial for resource allocation and patient management.
Purpose of the Study:
- To establish clinical, exercise, and hemodynamic factors predicting survival after cardiac transplantation.
- To identify predictors of long-term mortality in heart transplant recipients.
Main Methods:
- A cohort of 174 patients undergoing CTX between 1983 and 1999 was analyzed.
- Data collected included clinical, cardiopulmonary exercise testing (CPET), and hemodynamic measures.
- Patients were followed for a mean of 7.1 years, with all-cause mortality as the endpoint.
Main Results:
- Overall 5-year survival exceeded 80%, with an average annual mortality of 3.6%.
- Standard clinical, CPET, and hemodynamic variables were not significant predictors of mortality at a mean of 7 years post-CTX.
- Elevated serum creatinine (> 118 micromol/L), pulmonary capillary wedge pressure (PCWP > 12 mm Hg), and mean pulmonary artery pressure (> 25 mm Hg) were significant univariate predictors of mortality.
Conclusions:
- Long-term survival after CTX is generally favorable.
- Predictive value of standard clinical and exercise parameters for long-term mortality is limited.
- Elevated hemodynamic pressures may offer a weak indication of long-term survival, potentially related to ventricular compliance or pulmonary vascular resistance.
Background:
Cardiac transplantation (CTX) is now a viable option for patients with end-stage heart failure, but there remains a paucity of available donor hearts relative to the demand for them. Establishing prognosis after CTX can help direct this resource to patients most likely to benefit, as well as to help guide therapy for CTX recipients. Clinical, exercise, and hemodynamic factors associated with survival after CTX have not been well established.
Methods:
One hundred seventy-four randomly selected patients who underwent heart transplantation between 1983 and 1999 at Rikshospitalet University Hospital were included in the study. Data were collected as a part of routine posttransplantation management a mean of 3.5 +/- 2.1 years (+/- SD) after CTX. Clinical, cardiopulmonary exercise testing, and hemodynamic measures were performed, including measures of peak oxygen uptake (O(2)), ejection fraction, cardiac index, pulmonary capillary wedge pressure (PCWP), pulmonary artery pressure, creatinine, and the presence of coronary artery disease. Patients were followed up for a mean of 7.1 +/- 2.1 years; all-cause mortality was used as the end point for survival analysis.
Results:
During the follow-up period, 39 patients died; the average annual mortality was 3.6%. Peak O(2) was 19.6 +/- 5.6 mL/kg/min, representing 70.5 +/- 6.7% of the age-predicted value. Only right atrial pressure and PCWP differed between those who survived and those who died; both were slightly higher among those who died. By Cox proportional hazard analysis, there were no age-adjusted univariate or multivariate predictors of survival among continuous variables. Exploring various cut points revealed that serum creatinine > 118 micromol/L, PCWP > 12 mm Hg, and mean pulmonary artery pressure > 25 mm Hg were significant univariate predictors of mortality. These cut points for PCWP and pulmonary artery pressure generated hazard ratios of 2.3 and 2.9, respectively.
Conclusion:
Long-term survival after CTX was comparatively high in our cohort, with 5-year survival > 80%. Standard clinical, hemodynamic, and cardiopulmonary exercise test variables were not strong predictors of mortality in CTX patients a mean of 7 years after CTX. The association between elevated hemodynamic pressures and mortality, although weak, suggests that ventricular compliance, pulmonary vascular resistance, or both, may predict long-term survival after CTX.
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