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Reversal of end-stage heart failure is predicted by long-term therapeutic response rather than initial hemodynamic
T B Levine1, A B Levine, D Goldberg
1Department of Medicine, Henry Ford Hospital, Detroit, Mich. 48202, USA.
Insights
Patients awaiting heart transplants who improve hemodynamically during treatment are more likely to be removed from the waiting list. Idiopathic cardiomyopathy patients show better outcomes than ischemic cardiomyopathy patients with medical interventions.
Area of Science:
- Cardiology
- Transplantation Medicine
- Clinical Outcomes Research
Background:
- Long waiting lists for heart transplantation necessitate understanding factors influencing patient outcomes.
- Some patients improve clinically, leading to their removal from the transplant waiting list.
- Identifying characteristics of patients with good outcomes is crucial for resource allocation and treatment strategies.
Purpose of the Study:
- To differentiate patients awaiting heart transplantation who experience clinical improvement from those who continue to need a transplant.
- To identify predictors of favorable clinical outcomes in heart transplant candidates.
Main Methods:
- Retrospective analysis of right heart catheterization data from 60 heart transplant candidates.
- Patients divided into two groups: those removed from the waiting list due to improvement (Group A, n=18) and those who continued to require transplantation or died (Group B, n=42).
- Comparison of initial and serial hemodynamic and neurohormonal parameters between groups.
Main Results:
- Group A showed significant decreases in right atrial pressure and systolic pulmonary arterial pressure, with improved ejection fraction.
- Group B exhibited no significant changes in key hemodynamic parameters, though ejection fraction did improve.
- Idiopathic dilated cardiomyopathy was prevalent in Group A (12/18), while ischemic etiology dominated Group B (25/42).
Conclusions:
- Initial hemodynamic or neurohormonal presentation does not predict heart transplant waiting list outcomes.
- Patients who reverse hemodynamic derangements with therapy over time are more likely to have favorable clinical outcomes.
- Idiopathic cardiomyopathy patients appear to respond better to medical interventions than those with ischemic cardiomyopathy, suggesting improved prognosis.
Background:
Long waiting list periods for heart transplantation have led to clinical improvements for some patients resulting in their removal from the waiting list. This study sought to determine what characteristics differentiated those patients with a good clinical outcome from those who continued to need a transplant.
Methods:
The initial and final serial (every 3 months) right heart catheterization data of 60 patients awaiting transplantation were retrospectively analyzed, and the patients were divided into two groups: group A, patients who were taken off the list in follow-up because of improvement (n = 18 of 60), and group B who continued to require transplantation or died (n = 42 of 60).
Results:
For Group A, there were significant declines in right atrial pressure (9 +/- 4 to 4 +/- 3 mm Hg, initial versus final, p = 0.001), systolic pulmonary arterial pressure (51 +/- 17 to 34 +/- 6 mm Hg, p = 0.0001), with an increase in electron in ejection fraction (20% +/- 4% to 34% +/- 10%, p = 0.005). The change in cardiac output and norepinephrine level was not statistically significant. For Group B, there were no changes in the initial and final values of right atrial pressure, systolic pulmonary arterial pressure, pulmonary capillary wedge pressure, or norepinephrine levels. A significant rise in ejection fraction from 17% +/- 22% +/- 8%, p = 0.003 did occur. The majority of patients in group A (12 of 18) had idiopathic dilated cardiomyopathy. In contrast, an ischemic etiology was found in the majority of group B patients (25 of 42).
Conclusions:
This study shows that transplant waiting list outcome cannot be predicted from a patient's initial hemodynamic or neurohormonal presentation. Rather, those patients capable of reversing their hemodynamic derangements with therapy over time are most likely to sustain a favorable clinical outcome. It appears that patients with idiopathic rather than ischemic cardiomyopathy respond more favorably to medical interventions with improved prognosis.