Persistence of Pulmonary Hypertension in Patients undergoing Ventricular Assist Devices and Orthotopic Heart Transplantation

Abstract

BackgroundPulmonary hypertension (PH) is common in advanced heart failure which exhibits short-term improvement after left ventricular assist device (VAD) implantation or orthotopic heart transplantation (OHT), but long-term effects remain unknown. This study evaluated PH persistence after VAD as destination therapy (VAD-DT), bridge to transplant (VAD-BTT), or OHT-alone.MethodsA retrospective review of patients who underwent VAD-DT (n=164), VAD-BTT (n=111), or OHT-alone (n= 138) at a single tertiary-care center. Right heart catheterization (RHC) data was collected pre-, post-intervention (VAD and/or OHT), and 1-year from final intervention (latest-RHC) to evaluate the longitudinal hemodynamic course of right ventricular (RV) function and PH. PH (Group-II and Group-I) definitions were adapted from expert guidelines.ResultsAll groups showed significant improvements in mean pulmonary artery pressure (mPAP), pulmonary artery wedge pressure (PAWP), cardiac output (CO), and pulmonary vascular resistance (PVR) at each RHC with greatest improvement at post-intervention RHC (Post-VAD or Post-OHT). PH proportion reduced from 98% to 26% in VAD-BTT, 92% to 49% VAD-DT, and 76% to 28% from pre-intervention to latest-RHC. At latest-RHC mPAP remained elevated in all groups despite normalization of PAWP and PVR. VAD-supported patients exhibited suppressed pulmonary artery pulsatility index (PaPi< 3.7) with improvement only post-transplant at latest-RHC alongside improved right atrial pressures (RAP). Furthermore, post-transplant with PH at latest-RHC (n=60) exhibited lower survival (HR: 2.1 [95%CI: 1.3-3.4], p<0.001).ConclusionDespite an overall significant improvement in pulmonary pressures and PH proportion, a notable subset of patients exhibited residual RV derangements and PH persistence post-intervention. This post-intervention PH impacted post-transplant survival.Condensed AbstractThis study evaluates the longitudinal hemodynamic course of right ventricular (RV) function associated with heart-failure-related Pulmonary Hypertension (PH) and the impact of advanced interventions such as ventricular assist device and/or orthotopic heart transplant on PH persistence. Patients undergoing advanced interventions exhibit differences in PH prevalence which are dependent on the intervention received. Our results highlight despite an overall improvement in pulmonary pressures and PH, a notable number of patients exhibit RV dysfunction consistent with persistent PH. Furthermore, the persistence of PH after successful cardiac transplantation in a subset of patients continues to impact mortality in the long-term.