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Clinical and Exercise Test Determinants of Survival After Cardiac Transplantation^*

^* From the Division of Heart and Lung Diseases (Drs. Geiran, Simonsen, and Gullestad), Rikshopitalet, Oslo, Norway; and the Cardiology Division (Drs. Myers and Ghuyoumi), Palo Alto Veterans Affairs Health Care System, Palo Alto, CA.

Correspondence to: Jonathan Myers, PhD, Palo Alto Veterans Affairs Health Care System, Cardiology Division - 111C, 3801 Miranda Ave, Palo Alto, CA 94304

Background: Cardiac transplantation (CTX) is now a viable option for patients with end-stage heart failure, but there remains a paucity of available donor hearts relative to the demand for them. Establishing prognosis after CTX can help direct this resource to patients most likely to benefit, as well as to help guide therapy for CTX recipients. Clinical, exercise, and hemodynamic factors associated with survival after CTX have not been well established.

Methods: One hundred seventy-four randomly selected patients who underwent heart transplantation between 1983 and 1999 at Rikshospitalet University Hospital were included in the study. Data were collected as a part of routine posttransplantation management a mean of 3.5 ± 2.1 years (± SD) after CTX. Clinical, cardiopulmonary exercise testing, and hemodynamic measures were performed, including measures of peak oxygen uptake (O₂), ejection fraction, cardiac index, pulmonary capillary wedge pressure (PCWP), pulmonary artery pressure, creatinine, and the presence of coronary artery disease. Patients were followed up for a mean of 7.1 ± 2.1 years; all-cause mortality was used as the end point for survival analysis.

Results: During the follow-up period, 39 patients died; the average annual mortality was 3.6%. Peak O₂ was 19.6 ± 5.6 mL/kg/min, representing 70.5 ± 6.7% of the age-predicted value. Only right atrial pressure and PCWP differed between those who survived and those who died; both were slightly higher among those who died. By Cox proportional hazard analysis, there were no age-adjusted univariate or multivariate predictors of survival among continuous variables. Exploring various cut points revealed that serum creatinine > 118 µmol/L, PCWP > 12 mm Hg, and mean pulmonary artery pressure > 25 mm Hg were significant univariate predictors of mortality. These cut points for PCWP and pulmonary artery pressure generated hazard ratios of 2.3 and 2.9, respectively.

Conclusion: Long-term survival after CTX was comparatively high in our cohort, with 5-year survival > 80%. Standard clinical, hemodynamic, and cardiopulmonary exercise test variables were not strong predictors of mortality in CTX patients a mean of 7 years after CTX. The association between elevated hemodynamic pressures and mortality, although weak, suggests that ventricular compliance, pulmonary vascular resistance, or both, may predict long-term survival after CTX.

Key Words: cardiac transplantation • cardiopulmonary exercise testing • survival