- Email: [email protected]
Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart failure
Independent and Additive Prognostic Value of Right Ventricular Systolic Function and Pulmonary Artery Pressure in Patients With Chronic Heart Failure
plantation included various recipient and donor demographic, immunologic and peritransplant variables. Results: Actuarial survival was 72%, 58% and 39% at 1, 5 and 10 years, respectively. In the 65 patients who survived ⬎10 years, mean cardiac index was 2.9 1/m2 and mean ejection fraction was 58%. Transplant-related coronary artery disease (TRCAD) was detected in only 14 of the 65 patients (22%). By multivariable analysis, the only risk factor found to adversely affect long-term survival was a pretransplant diagnosis of ischemic cardiomyopathy (p ⫽ 0.04). Conclusions: Long-term survivors maintain normal hemodynamic function of the allografts with a low prevalence of TRCAD. It is possible that similar risk factors that lead to coronary artery disease in native vessels continue to operate in the post-transplant period, thereby contributing to adverse outcomes after cardiac transplantation. Perspective: At a single center with a large transplant population, long-term survival was in those patients with preserved function and without evidence of coronary artery disease. While there is a certain Darwinian survival component to these findings, they nonetheless indicate that efforts to preserve ventricular function and limit post-transplant coronary disease are necessary to optimize clinical outcome and survival. RC
Ghio S, Gavazzi A, Campana C, et al. J Am Coll Cardiol 2001: 37:183– 8. Study Question: The investigators evaluated the coupling between right ventricular ejection fraction (RVEF) and pulmonary artery pressure (PAP) to determine whether the interaction between these hemodynamic parameters would offer better prognostic stratification of patients with heart failure. Methods: Right heart catheterization was performed in 377 consecutive patients with heart failure using methods that permitted estimation of RVEF, as well as estimation of pulmonary wedge pressure. During a median follow-up period of 17 ⫾ 9 months, 105 patients died and 35 underwent urgent heart transplantation. Pulmonary artery pressure and thermodilution-derived RVEF were inversely related (r ⫽ 0.66, p ⬍ 0.001). However, on Cox multivariate survival analysis, no interaction between such variables was found, and both turned out to be independent prognostic predictors (p ⬍ 0.001). It was found that RVEF was preserved in some patients with pulmonary hypertension and that the prognosis of these patients was similar to that of the patients with normal PAP. In contrast, when PAP was normal, reduced RV function did not carry an additional risk. Conclusions: These observations emphasize the necessity of combining the right heart hemodynamic variables with a functional evaluation of the RV when trying to define the individual risk of patients with heart failure. Perspective: The importance of right heart function in heart failure has been recognized for many years, with decompensation of the right ventricle being recognized as a harbinger for mortal events. The correlations in this study are observational; intrinsic pulmonary disease and right ventricular ischemia or infarction may have contributed to the discordant findings. RC
Late Rejection Is a Predictor of Transplant Coronary Artery Disease in Children Mulla NF, Johnston JK, Vander Dussen L, et al. J Am Coll Cardiol 2001;37:243–50. Study Question: The study objectives were to determine post-transplant coronary artery disease (TxCAD) incidence, predisposing factors and optimal timing for re-transplantation (re-Tx) in pediatric heart transplantation (Tx) recipients. Of note, there is limited information in children regarding the risk factors and timing of listing for re-Tx when coronary artery disease has developed. Methods: The records of children who survived ⬎ 1 year post-Tx at a single site (Loma Linda University) were reviewed. Nonimmune and immune risk factors were analyzed. Results: TxCAD was documented in 24 of 210 children who had a successful cardiac transplantation. Freedom from TxCAD was 92 ⫾ 2% and 75 ⫾ 5% at 5 and 10 years post-Tx, respectively. The TxCAD diagnosis was established at autopsy in 10 asymptomatic patients who died suddenly within 9 months following the most recent negative angiograms. The remaining 14 children had angiographic diagnoses of TxCAD and had symptoms and/or graft dysfunction or positive stress studies. Eleven patients underwent re-Tx within 7 months of diagnosis; nine survived. Only late rejection frequency and severity were independent predictors of TxCAD development. Freedom
Factors Affecting Long-Term Survival (>10 Years) After Cardiac Transplantation in the Cyclosporine Era John R, Rajasinghe HA, Itescu S, et al. J Am Coll Cardiol 2001; 37:189 –94. Study Question: The aim of the study was to determine long-term survival (⬎10 years) after cardiac transplantation in the cyclosporine era and identify risk factors influencing long-term survival. Methods: 195 patients underwent heart transplantation at a single center for the treatment of end-stage heart disease. Multivariable logistic regression analysis of pretransplant risk factors affecting long-term survival after cardiac trans-
ACC CURRENT JOURNAL REVIEW May/Jun 2001
56
plantation included various recipient and donor demographic, immunologic and peritransplant variables. Results: Actuarial survival was 72%, 58% and 39% at 1, 5 and 10 years, respectively. In the 65 patients who survived ⬎10 years, mean cardiac index was 2.9 1/m2 and mean ejection fraction was 58%. Transplant-related coronary artery disease (TRCAD) was detected in only 14 of the 65 patients (22%). By multivariable analysis, the only risk factor found to adversely affect long-term survival was a pretransplant diagnosis of ischemic cardiomyopathy (p ⫽ 0.04). Conclusions: Long-term survivors maintain normal hemodynamic function of the allografts with a low prevalence of TRCAD. It is possible that similar risk factors that lead to coronary artery disease in native vessels continue to operate in the post-transplant period, thereby contributing to adverse outcomes after cardiac transplantation. Perspective: At a single center with a large transplant population, long-term survival was in those patients with preserved function and without evidence of coronary artery disease. While there is a certain Darwinian survival component to these findings, they nonetheless indicate that efforts to preserve ventricular function and limit post-transplant coronary disease are necessary to optimize clinical outcome and survival. RC
Ghio S, Gavazzi A, Campana C, et al. J Am Coll Cardiol 2001: 37:183– 8. Study Question: The investigators evaluated the coupling between right ventricular ejection fraction (RVEF) and pulmonary artery pressure (PAP) to determine whether the interaction between these hemodynamic parameters would offer better prognostic stratification of patients with heart failure. Methods: Right heart catheterization was performed in 377 consecutive patients with heart failure using methods that permitted estimation of RVEF, as well as estimation of pulmonary wedge pressure. During a median follow-up period of 17 ⫾ 9 months, 105 patients died and 35 underwent urgent heart transplantation. Pulmonary artery pressure and thermodilution-derived RVEF were inversely related (r ⫽ 0.66, p ⬍ 0.001). However, on Cox multivariate survival analysis, no interaction between such variables was found, and both turned out to be independent prognostic predictors (p ⬍ 0.001). It was found that RVEF was preserved in some patients with pulmonary hypertension and that the prognosis of these patients was similar to that of the patients with normal PAP. In contrast, when PAP was normal, reduced RV function did not carry an additional risk. Conclusions: These observations emphasize the necessity of combining the right heart hemodynamic variables with a functional evaluation of the RV when trying to define the individual risk of patients with heart failure. Perspective: The importance of right heart function in heart failure has been recognized for many years, with decompensation of the right ventricle being recognized as a harbinger for mortal events. The correlations in this study are observational; intrinsic pulmonary disease and right ventricular ischemia or infarction may have contributed to the discordant findings. RC
Late Rejection Is a Predictor of Transplant Coronary Artery Disease in Children Mulla NF, Johnston JK, Vander Dussen L, et al. J Am Coll Cardiol 2001;37:243–50. Study Question: The study objectives were to determine post-transplant coronary artery disease (TxCAD) incidence, predisposing factors and optimal timing for re-transplantation (re-Tx) in pediatric heart transplantation (Tx) recipients. Of note, there is limited information in children regarding the risk factors and timing of listing for re-Tx when coronary artery disease has developed. Methods: The records of children who survived ⬎ 1 year post-Tx at a single site (Loma Linda University) were reviewed. Nonimmune and immune risk factors were analyzed. Results: TxCAD was documented in 24 of 210 children who had a successful cardiac transplantation. Freedom from TxCAD was 92 ⫾ 2% and 75 ⫾ 5% at 5 and 10 years post-Tx, respectively. The TxCAD diagnosis was established at autopsy in 10 asymptomatic patients who died suddenly within 9 months following the most recent negative angiograms. The remaining 14 children had angiographic diagnoses of TxCAD and had symptoms and/or graft dysfunction or positive stress studies. Eleven patients underwent re-Tx within 7 months of diagnosis; nine survived. Only late rejection frequency and severity were independent predictors of TxCAD development. Freedom
Factors Affecting Long-Term Survival (>10 Years) After Cardiac Transplantation in the Cyclosporine Era John R, Rajasinghe HA, Itescu S, et al. J Am Coll Cardiol 2001; 37:189 –94. Study Question: The aim of the study was to determine long-term survival (⬎10 years) after cardiac transplantation in the cyclosporine era and identify risk factors influencing long-term survival. Methods: 195 patients underwent heart transplantation at a single center for the treatment of end-stage heart disease. Multivariable logistic regression analysis of pretransplant risk factors affecting long-term survival after cardiac trans-
ACC CURRENT JOURNAL REVIEW May/Jun 2001
56