What is high risk? Redefining elevated pulmonary vascular resistance index in pediatric heart transplantation

doi:10.1016/j.healun.2011.08.021

The Journal of Heart and Lung Transplantation

Volume 31, Issue 1, January 2012, Pages 61-66

https://doi.org/10.1016/j.healun.2011.08.021 Get rights and content

Background

Currently, pulmonary vascular resistance index (PVRI) >6 WU × m² (indexed units) is generally considered a contraindication to isolated orthotopic heart transplantation (OHT). However, this has been questioned in the literature.

Methods

A retrospective review was performed on all patients <18 years old who underwent primary OHT for cardiomyopathy. Data were collected with regard to demographics, pre-operative hemodynamics, need for pre-operative mechanical circulatory support, vasodilator reactivity and 30-day mortality (30dM). A receiver operating characteristic (ROC) curve was used to establish an optimal threshold. Uni- and multivariate logistic regressions were performed to assess the influence of PVRI on 30dM.

Results

Complete data were available for 158 cardiomyopathy patients <18 years of age, who underwent primary OHT between June 1984 and November 2010. The ROC curve yielded a threshold of 9.290 indexed units. Four of 19 patients (21.1%) with PVRI >9 died in the first 30 days. In patients with PVRI <9, there was only 1 death among 139 patients (0.7%). Odds of mortality increased incrementally with PVRI as a continuous variable, with an odds ratio (OR) of 1.35 per indexed unit (95% confidence interval 1.12 to 1.63). PVRI was dichomotomized (PVRId) using the previously established threshold and revealed an increasing risk of mortality, OR 36.80 (95% confidence interval 3.86 to 350.90), with a PVRI of >9 indexed units.

Conclusions

Using a PVRI >6 as a contraindication to isolated OHT may be too restrictive. Patients with PVRI ≤9 do not appear to be at increased risk of early mortality. In patients with PVRI >9, 30-day survival was 78.9% in this study. This represents a viable alternative to heart–lung transplantation.

Section snippets

Patient selection and population

A retrospective chart review was performed after approval from the institutional review board at Columbia University. The demographic, pre-operative hemodynamic, need for pre-operative mechanical circulatory support (MCS) and 30-day mortality (30dM) data were collected for all patients <18 years old undergoing primary orthotopic heart transplantation for cardiomyopathy at the Morgan Stanley Children's Hospital of New York Presbyterian between June 1, 1984 and November 30, 2010. Patients with a

Results

A total of 334 heart transplantations were performed in patients <18 years old between June 1, 1984 and November 30, 2010. Of these patients, there were 102 patients with complex congenital heart disease, 2 patients with heterotopic transplantation and 19 patients had retransplantations. Pre-transplant catheterization data were not available for 53 patients. These 174 patients were excluded from further analyses leaving 158 patients with the diagnosis of cardiomyopathy and complete data

Discussion

The risk of early right ventricular failure after heart transplantation has been the basis of the relatively strict PVRI criterion governing transplant candidacy.1, 2, 3, 4, 5 However, this criterion may be challenged as successful transplantation in selected adults and children with PVRI ≥9 indexed units has been reported.¹ Given previous success with high-risk transplantation, orthotopic heart transplantation is offered to children with elevated PVRI as an institutional policy. This study has

Disclosure statement

The authors have no conflicts of interest to disclose. This study was supported by the NIH Summer Research Fellowship at Columbia University, College of Physicians & Surgeons. We thank Rose Rodriguez, PNP, Diora Merchant and Isaac Dinner, PhD, for their help with this study.

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Original clinical scienceWhat is high risk? Redefining elevated pulmonary vascular resistance index in pediatric heart transplantation

Background

Methods

Results

Conclusions

Section snippets

Patient selection and population

Results

Discussion

Disclosure statement

Prog Pediatr Cardiol

J Heart Lung Transplant

Am J Transplant

J Thorac Cardiovasc Surg

J Heart Lung Transplant

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Cardiovasc Pathol

Chest

J Heart Lung Transplant

Original clinical science
What is high risk? Redefining elevated pulmonary vascular resistance index in pediatric heart transplantation