COPD in patients after heart transplantation is associated with a prolonged hospital stay, early posttransplant atrial fibrillation, and impaired posttransplant survival

Abstract

ObjectivesCOPD is associated with reduced physical activity, an increased risk for pulmonary infections, and impaired survival in nontransplant patients. The aim of this study was to investigate the influence of COPD in patients after heart transplantation (HTX).MethodsWe performed an observational retrospective single-center study of 259 patients receiving HTX at Heidelberg University Hospital between 2003 and 2012. Patients were stratified by the Tiffeneau index (forced expiratory volume in 1 second/forced vital capacity [FEV1/FVC]) <0.70 before HTX. The analysis included demographics, posttransplant medication, length of the initial hospital stay after HTX, early posttransplant atrial fibrillation (AF), mortality, and causes of death.ResultsIn total, 63 (24.3%) patients had an FEV1/FVC <0.70. These patients showed a prolonged hospital stay after HTX (52.0 days vs 43.4 days, mean difference (MD) = 8.6 days, 95% CI: 0.2, 17.0 days), a higher rate of early posttransplant AF (19.0% vs 8.2%, MD = 10.8%, 95% CI: 0.4%, 21.2%), and an increased 30-day mortality (9.5% vs 2.6%, HR = 3.79, 95% CI: 1.16, 12.40). Kaplan– Meier analysis showed a significant inferior 5-year survival in patients with an FEV1/FVC <0.70, along with a higher percentage of death due to transplant failure and infection/sepsis. In addition, a multivariate analysis for mortality within 5 years after HTX indicated an FEV1/FVC <0.70 as a significant risk factor for impaired 5-year posttransplant survival (HR =4.77, 95% CI: 2.76, 8.22).ConclusionCOPD in patients after HTX is associated with a prolonged hospital stay, early posttransplant AF, and impaired posttransplant survival.

Elevated pre‐transplant pulmonary vascular resistance is associated with early post‐transplant atrial fibrillation and mortality

“…A further change of medical treatment during the study period was the clinical introduction of ivabradine in 2006, which is used for heart rate reduction in patients after HTX. However, there was no significant difference in the use of ivabradine between both groups …”

“…Extensive univariate analyses were performed to test for differences between groups including recipient data, previous open-heart surgery, principal diagnosis for HTX, donor data, transplant sex mismatch, perioperative data, and post-transplant medication including immunosuppressive drug therapy. [28][29][30][31][32][33][34] The influence of an elevated native PVR before HTX ≥ 300 dyn·s·cm À5 (≥3.75 Wood units) on post-transplant mortality was further analysed and adjusted for specific predetermined risk factors by performing a multivariate analysis (Cox regression model). The following six clinically relevant parameters were included based on a predetermined model: native PVR before HTX ≥ 300 dyn·s·cm À5 (≥3.75 Wood units), recipient age (>60.0 years), coronary artery disease, previous openheart surgery, donor age (>40.0 years), and ischaemic time (≥240 min).…”

“…In order to avoid biased regression coefficients and to ensure a stable number of events (deceased patients) per analysed variable, no further clinically less relevant parameters were included in this multivariate analysis. [28][29][30][31][32][33][34] Given the long study period, a sensitivity analysis was carried out to test the robustness of the study results and to investigate a possible era effect. Therefore, as the initial standard immunosuppressive drug therapy was changed during the study period, a subgroup analysis was performed with patients receiving CsA and azathioprine.…”

“…According to the ethical approval, no additional written informed consent was required for this observational retrospective single-centre study as only routine clinical data were used. [28][29][30][31][32][33][34] The latest RHC before HTX was used to stratify patients based on their pre-transplant PVR, which was classified as follows: normal pre-transplant PVR < 200 dyn·s·cm À5 (<2.5 Wood units); mildly elevated pre-transplant PVR = 200 to 299 dyn·s·cm À5 (2.5 to 3.74 Wood units); moderately elevated pre-transplant PVR = 300 to 399 dyn·s·cm À5 (3.75 to 4.99 Wood units); and severely elevated pre-transplant PVR ≥ 400 dyn·s·cm À5 (≥5.0 Wood units). In an attempt to find the optimal pre-transplant PVR discrimination threshold, we performed a receiver operating characteristic analysis for 30 day all-cause mortality after HTX, which indicated a pretransplant PVR of 285 dyn·s·cm À5 (3.56 Wood units) as an optimal cut-off for HTX listing.…”

“…After discharge, patients were followed up monthly within the first 6 months after HTX, then bimonthly between months 6 and 12 after HTX, and thereafter usually three to four times annually. [28][29][30][31][32][33][34][35][36]…”