Pulmonary Hypertension vs Age for Predicting Outcomes in Heart Transplant

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As a bridge to transplant, LVADs may improve the mean arterial pressure/mean pulmonary arterial pressure ratio.
As a bridge to transplant, LVADs may improve the mean arterial pressure/mean pulmonary arterial pressure ratio.

Hemodynamics, increased right ventricular (RV) afterload, and pulmonary hypertension may be more important than age in predicting risk for morbidity and mortality outcomes following heart transplantation, according to an editorial published in the Journal of Cardiothoracic and Vascular Anesthesia.

With the advent of left ventricular assist devices (LVADs) and the recognition of the benefits associated with early revascularization, the treatment of heart failure has improved outcomes worldwide. Despite these advances in clinical practice, heart transplantation still comprises approximately 4000 to 5000 heart-related procedures performed annually.

Currently, the medical community is challenging the long-held belief that older age represents a contraindication to heart transplant, a challenge derived primarily from changes in patient demographics and the longer life expectancy being observed in the general population. Many studies that point to age as an indicator for prognosis in patients undergoing heart transplant fail to establish an age cut-off value, representing a potential limitation to using this variable in risk analysis.

Rather than age, the investigators of this editorial suggested that increased RV afterload and ensuing RV dysfunction represent important risk factors for poor outcomes following heart transplant. Pulmonary hypertension, RV failure, and cardiopulmonary bypass time are additional considerations that can provide better insight into post-transplant outcomes compared with age.

According to the investigators, pretransplant bridging therapy with LVADs may result in an improved mean arterial pressure/mean pulmonary arterial pressure ratio, which may help in providing more optimal “algorithms to better identify transplant candidates most likely to benefit from heart transplant.”

Reference

Bolliger D, Bouchez S, Mauermann E. Re-examining factors associated with mortality after heart transplantation: a focus on recipient age and relative pulmonary hypertension [published online November 4, 2017]. J Cardiothorac Vasc Anesth. doi:10.1053/j.jvca.2017.11.004

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