INFLUENCE OF PREOPERATIVE TRANSPULMONARY GRADIENT ON LATE MORTALITY AFTER ORTHOTOPIC HEART-TRANSPLANTATION

  • 1 September 1990
    • journal article
    • research article
    • Vol. 9  (5) , 526-537
Abstract
We received the transpulmonary gradient, pulmonary arterial systolic pressure, pulmonary vascular resistance (Wood units), and pulmonary vascular resistance index (Wood units .times. Body surface area), recorded preoperatively in 109 recipients aged 44.6 .+-. 13.5 (mean .+-. SD) years who underwent orthotopic heart transplantation between March 1984 and March 1988, to identify which measure of pulmonary hypertension most accurately predicts poor outcome after orthotopic heart transplantation. These recipients were followed up as many as 57 (24.7 .+-. 14.5) months after the transplant procedure. Preoperative hemodynamic values were as follows: transpulmonary gradient, 10.4 .+-. 4.7 mmHg; pulmonary artery systolic pressure, 53.6 .+-. 14.8 mm Hg; pulmonary vascular resistance, 2.7 .+-. 1.8 Wood units; pulmonary vascular resistance index, 4.9 .+-. 2.7. Nineteen recipients died within 1 year after orthotopic heart transplantation. Causes of death were acute rejection (8), chronic rejection (1), infection (2), nonspecific orthotopic heart transplant failure (4), bowel ischemia (1), pancreatitis (1), lymphoma (1), and liver failure (1). Preoperative pulmonary arterial systolic pressure, pulmonary vascular resistance, and pulmonary vascular resistance index were not predictive of 1-month, 6-month, or 1-year mortality. One month mortality rates of orthotopic heart transplant recipients with transpulmonary gradient .gtoreq. 12 mm Hg and those with transpulmonary gradient < 12 mm Hg were not significantly different (11% vs 3%; p = 0.12). The 6-month mortality rate of orthotopic heart transplant recipients with transpulmonary gradient .gtoreq. 12 mm Hg, however, was five times greater than that of orthotopic heart transplant recipients with transpulmonary gradient < 12 mm Hg (24% vs 5%; p = 0.003), and 12-month mortality of orthotopic heart transplant recipients with transpulmonary gradient .gtoreq. 12 mm Hg was increased sevenfold when compared with that of orthotopic heart transplant recipients with transpulmonary gradient < 12 mm Hg (36% vs 5%; p = 0.0005). These results suggest that presently used measures of pulmonary hypertension do not predit mortality in the first month after orthotopic heart transplantation, but that elevated preoperative transpulmonary gradient is associated with a significant increase in mortality at 6 and 12 months after orthotopic heart transplantation. Prospective randomized trials are needed to determine whether extended preload and afterload reduction before and/or after transplant will favorably influence long-term prognosis of orthotopic heart transplant recipients with elevated preoperative transpulmonary gradient.

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