BACKGROUND
Current guidelines require patients with heart failure (HF) being evaluated for advanced
therapies such as heart transplantation or left ventricular assist device (LVAD) implantation
to undergo right heart catheterization to identify the presence of pulmonary hypertension
(PH). PH that is irreversible is a relative contraindication to heart transplantation
and associated with poor prognosis. Based on the International Society for Heart and
Lung Transplantation guidelines, reversibility is assessed with a vasodilator challenge
if pulmonary artery systolic pressure (PASP) is > 50 mmHg, and either transpulmonary
gradient (TPG) is > 15 mmHg or pulmonary vascular resistance (PVR) is > 3 WU. However,
the most updated 6th World Symposium on Pulmonary Hypertension defined PH more broadly
as to mean pulmonary artery pressure (mPAP) > 20 mmHg. As such, there is an intermediate
group of patients with mild PH not meeting the threshold to receive a vasodilator
challenge to determine whether mild PH is reversible. Our aim was to assess the hemodynamic
characteristics of this group and determine whether they are at risk of worse clinical
outcomes.
METHODS AND RESULTS
A retrospective analysis was performed of 175 patients with heart failure who were
referred to our centre for right heart catheterization as part of evaluation for candidacy
for advanced heart failure therapies. Patients were divided into three groups based
on initial hemodynamics: patients with mPAP < 20 mmHg (No-PH, n=57), patients with
significant PH meeting current guideline criteria for a vasodilator challenge (PH+V,
n=41) and patients with mPAP > 20 mmHg that did not meet the threshold for vasodilator
challenge (PH-V, n=77). Compared to the No-PH group, the PH-V group did not have a
significantly different stroke volume index or cardiac index, however, they had a
significantly higher PVR, indicating greater resistive load, and lower pulmonary artery
compliance (PAC), indicating higher pulsatile load (Table). The PH-V group also had
significantly higher mean right atrial pressure (mRAP) compared to the No-PH group,
suggesting right ventricular decompensation. Composite pre-and post-intervention three-year
survival after catheterization appeared lower in both PH+V and PH-V patients compared
to the No-PH group (Figure).
CONCLUSION
HF patients assessed for advanced therapies identified as having mild PH have increased
pulmonary pulsatile and resistive load, along with elevated right-sided filling pressures,
and have increased mortality. Currently, this group does not undergo vasodilator testing
to determine PH reversibility. Whether mild PH is modifiable, and its relationship
to outcomes after heart transplantation or LVAD implant requires further study.
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© 2021 Published by Elsevier Inc.
