Clinical features, exercise hemodynamics, and determinants of left ventricular elevated filling pressure in heart-transplanted patients

Abstract

SummaryThis study aimed to assess clinical, functional, and hemodynamic characteristics of heart-transplanted (HTX) patients during exercise. We performed comprehensive echocardiographic graft function assessment during invasive hemodynamic semi-supine exercise test in 57 HTX patients. According to hemodynamics findings, patients were divided into Group A: normal left ventricular (LV) filling pressure (FP): pulmonary capillary wedge pressure (PCWP) <15 mmHg at rest and <25 mmHg at peak exercise, and Group B: elevated LV-FP: PCWP ≥15 mmHg at rest or ≥25 mmHg at peak exercise. Thirty-one patients (54%) had normal LV-FP and 26 patients (46%) had elevated LV-FP. The latter had higher cumulative rejection burden (P < 0.01) and were more symptomatic (NYHA class >1) (P < 0.05), and cardiac allograft vasculopathy (CAV) was more prevalent (P < 0.05). With exercise, the changes in both left-and right-sided filling pressures were significantly increased, whereas LV longitudinal myocardial deformation was lower (P < 0.05) in patients with elevated LV-FP than in patients with normal LV-FP. No between-group difference was observed for cardiac index or LV ejection fraction (LVEF) during exercise. In conclusion, elevated LV-FP can be demonstrated in approximately 50% of HTX patients. Patients with elevated LV-FP have impaired myocardial deformation capacity, higher prevalence of CAV, and higher rejection burden, and were more symptomatic. Exercise test with the assessment of longitudinal myocardial deformation should be considered in routine surveillance of HTX patients as a marker of restrictive filling (ClinicalTrials.gov Identifier: NCT02077764).

Prognostic value of exercise myocardial deformation and haemodynamics in long‐term heart‐transplanted patients

“…Studies of invasive haemodynamics demonstrate that resting LV and RV filling pressures tend to normalize in most HTx patients during the first months after surgery, whereas pulmonary arterial compliance remains reduced. 11,12 The distinct differences in haemodynamics at peak exercise between HTx patients and healthy controls emphasize that assessment of invasive haemodynamics during resting conditions falls short as a measure of systolic and diastolic graft performance. However, the haemodynamic response to exercise is clearly abnormal in HTx patients.…”

“…However, the haemodynamic response to exercise is clearly abnormal in HTx patients. 12 The prognostic result of these hazards may be reflected in the LVGLS magnitude. 12 This documented inability to increase CI adequately during exercise might be attributable to several factors such as impaired ventricular contractile reserve, 28,29 an inadequate stroke volume reserve coupled with chronotropic incompetence, 30,31 increased afterload, 32 and RV dysfunction.…”

“…12,14,15 The patients were followed prospectively from the time of exercise test until death or censoring on the 10 October 2018, whichever came first. All patients were transplanted a minimum of 12 months before study entry and were included at the time of their routine annual coronary angiography.…”

“…12 A multistage symptom-limited, semi-supine bicycle exercise test was performed using the Cardiac Stress Table (Lode B.V., Netherlands). The catheter was introduced into the right jugular vein using an ultrasound-guided technique and advanced pressure waveforms, and guided into the pulmonary artery using fluoroscopy.…”

“…10 Previous studies have demonstrated that loading conditions in patients with CAV are often within the normal range during resting conditions. 12 However, little is known about the prognostic value of invasive haemodynamic parameters in long-term follow-up HTx patients. 13 Exercise-induced elevated LV filling pressure has been associated with CAV and previous rejection burden.…”