[Short-term survival after heart transplantation: the relationships between preoperative hemodynamics, organ function...

Pulmonary hypertension is known to affect prognosis of cardiac allograft recipients. Aim of this study is to elucidate the mechanisms relating preoperative hemodynamics to early post-transplant mortality.

Hemodynamic and pre- and postoperative clinical data of 122 heart transplant recipients were reviewed with respect to early mortality (within 1 month or in-hospital). The relationships between hemodynamics and mortality were studied by means of univariate and multivariate analysis of absolute data and at different cut-off values of hemodynamic parameters.

The following hemodynamic parameters were significantly different between survivors (n = 107) and non-survivors (n = 15): right atrial pressure (7.7 +/- 4.7 vs. 12.1 +/- 8.6 mm Hg, p < 0.004), pulmonary vascular resistance (2.57 +/- 1.44 vs. 3.72 +/- 1.88 Wood units, p < 0.007), pulmonary vascular resistance index (4.43 +/- 2.53 vs. 6.53 +/- 3.28 Wood units x m2, p < 0.005), and transpulmonary gradient (8.8 +/- 4.8 vs. 12.3 +/- 6.4 mm Hg, p < 0.02). Right atrial pressure and pulmonary vascular resistance index showed an independent value at stepwise multiple logistic regression analysis (p < 0.008 and < 0.03 respectively). When mortality was tested using cut-off values, it was significantly higher with right atrial pressure > or = 12 (7/28 vs 8/94, p < 0.05), pulmonary vascular resistance index > or = 8 (6/13 vs 9/109, p < 0.0005), and transpulmonary gradient > or = 15 (5/13 vs 10/109, p < 0.01). High right atrial pressure, pulmonary vascular resistance index, and transpulmonary gradient were associated with higher preoperative bilirubin (p < 0.03), which was significantly superior in non-survivors (1.44 +/- 1.53 vs. 0.83 +/- 0.61 mg/dl, p < 0.02). Postoperatively, severe right ventricular failure, severe renal failure and infections within 1 month were all strongly associated with an increased mortality (p < 0.00003); they were more common in patients with high preoperative right filling pressure (9% vs. 43%, p < 0.00002) and/or high pulmonary vascular resistance index (14% vs. 38%, p < 0.03), in those with high right atrial pressure (9% vs. 35%, p < 0.0009), and in those with high pulmonary vascular resistance index (17% vs. 58%, p < 0.002) respectively. Mortality after acute rejection within 1 month was significantly higher in patients with high preoperative right atrial pressure (8% vs. 57%, p < 0.006).

Besides pulmonary hypertension, elevated preoperative right filling pressure appears to indicate an increased risk of early death after transplantation; pre- and postoperative end-organ dysfunction and post-transplant complications are more common or more threatening in this setting.