Persistence of pulmonary hypertension in patients undergoing ventricular assist devices and orthotopic heart transplantation.

ABSTRACT

Pulmonary hypertension (PH) is common in advanced heart failure and often improves quickly after left ventricular assist device (VAD) implantation or orthotopic heart transplantation (OHT), but long-term effects and outcomes are not well-described. This study evaluated PH persistence after VAD as destination therapy (VAD-DT), bridge to transplant (VAD-OHT), or OHT-alone. The study constituted a retrospective review of patients who underwent VAD-DT (n = 164), VAD-OHT (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 function and pulmonary vasculature. PH (Group II and Group I) definitions were adapted from expert guidelines. All groups showed significant improvements in mean pulmonary artery pressure (mPAP), pulmonary artery wedge pressure (PAWP), cardiac output, and pulmonary vascular resistance (PVR) at each RHC with greatest improvement at post-intervention RHC (post-VAD or post-OHT). PH was reduced from 98% to 26% in VAD-OHT, 92%-49% in VAD-DT, and 76%-28% in OHT-alone from preintervention 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 posttransplant at latest-RHC. Posttransplant patients with PH at latest-RHC (n = 60) exhibited lower survival (HR 2.1 [95% CI 1.3-3.4], p < 0.001). Despite an overall significant improvement in pulmonary pressures and PH proportion, a notable subset of patients exhibited PH post-intervention. Post-intervention PH was associated with lower posttransplant survival.