Implication of the new definition of pulmonary hypertension in patients evaluated for heart transplantation
Graphical abstract
The new definition of pulmonary hypertension in patients with chronic heart failure evaluated for cardiac transplantation.
Introduction
It is estimated that around 65% of patients with chronic heart failure (HF) develop pulmonary hypertension (PH) [1,2]. Pulmonary hypertension in the setting of chronic HF results from several complex mechanisms, including increased pressure in the left atrium transmitted to the pulmonary circulation, vascular remodeling, arteriolar intimal thickening, and microvascular thrombosis. [3,4]. In the setting of chronic HF, PH has been associated with poor outcomes including increased mortality. As such, screening for pulmonary hypertension is paramount before considering heart transplantation or cardiac assistance [[5], [6], [7], [8]].
From 1973 to 2018, PH was defined by the World Symposium on Pulmonary Hypertension (WSPH) as a mean pulmonary arterial pressure (mPAP) equal or superior to 25 mmHg [9]. Following the study of US Veterans including all indications of right heart catheterization (RHC), the 2018 6th WSPH changed the definition of PH to mPAP >20 mmHg to include patients previously considered as having a borderline PH [10]. This new threshold was implemented by the 2022 guidelines by European Society of Cardiology and the European Respiratory Society guideline [11].
Nonetheless, little is known regarding the implication of this new criteria for PH in a population of severe HF potentially eligible for heart transplant. Our primary hypothesis is that patients with mPAP between 20 and 25 mmHg present a high-risk profile with a high risk of worst outcomes including mortality. Our secondary hypothesis is that the threshold of mPAP >20 mmHg is clinically meaningful in the specific population of patients with severe chronic heart failure evaluated for heart transplantation.
Section snippets
Study design and population
The data supporting the findings of the present study are available from the corresponding author upon reasonable request. The study population consisted of consecutive patients with chronic HF addressed for RHC evaluation for heart transplantation eligibility assessment at the Institut de Cardiologie of the Pitié-Salpêtrière Hospital between January 1ST, 2000 and June 30th, 2020. Patients undergoing RHC for other motives such as chronic constrictive pericarditis, post-heart transplantation
Baseline clinical characteristics
Between January 2000 and June 2020, 782 patients with chronic HF underwent RHC to assess eligibility for heart transplantation, of whom 89 were excluded because of missing data. Among the 693 patients analyzed, 77.5% (n = 537) had mPAP ≥ 25mmHg, 9.8% (n = 68) had mPAP ≤ 20 mmHg, and 12.7% (n = 88) had mPAP 20–25 mmHg (flow chart in supplemental appendix). The distribution of mPAP is provided in Fig. 1.
Baseline characteristics according to each category are described in Table 1. Patients of
Discussion
In the present cohort study with a long-term follow-up of patients with severe heart failure assessed for eligibility for heart transplantation, individuals with mPAP between 20 and 25 mmHg have: 1/ frequent co-morbidities such as diabetes, atrial fibrillation, chronic kidney disease and older age; 2/ severe symptoms, high NT-pro BNP and a decreased cardiac output; 3/ frequent pre-capillary PH with elevated pulmonary vascular resistance 4/ have a higher risk of mortality compared with patients
Funding
ACTION study group.
Author contributions
MZ, GM, QM, JS drafted the project, collected the data and established the statistical methods. NP contributed to the methodological and statistical analysis. All the authors contributed to the drafting of the manuscript and the critical review.
Declaration of Competing Interest
Gilles Montalescot reports research grants, funding or consulting fees from Abbott, Amgen, AstraZeneca, Axis, Bayer, BMS, Boehringer-Ingelheim, Boston-Scientific, Cell Prothera, CSL Behring, Idorsia, Leo-Pharma, Lilly, Medtronic, Novartis, Pfizer, Quantum Genomics, Sanofi, Terumo; Michel Zeitouni reports research grants, funding or consulting fees from Fédération Française de Cardiologie, Institut Servier, BMS/Pfizer, AstraZeneca and Amgen; Johanne Silvain reports reports research grants,
Acknowledgements
None.
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