The Journal of Heart and Lung Transplantation
International Society for Heart and Lung Transplantation.

Hemodynamic markers of pulmonary vasculopathy for prediction of early right heart failure and mortality after heart transplantation

Published:October 08, 2022DOI:


      Elevated pulmonary vascular resistance (PVR) is broadly accepted as an imminent risk factor for mortality after heart transplantation (HTx). However, no current HTx recipient risk score includes PVR or other hemodynamic parameters. This study examined the utility of various hemodynamic parameters for risk stratification in a contemporary HTx population.


      Patients from seven German HTx centers undergoing HTx between 2011 and 2015 were included retrospectively. Established risk factors and complete hemodynamic datasets before HTx were analyzed. Outcome measures were overall all-cause mortality, 12-month mortality, and right heart failure (RHF) after HTx.


      The final analysis included 333 patients (28% female) with a median age of 54 (IQR 46-60) years. The median mean pulmonary artery pressure was 30 (IQR 23-38) mm Hg, transpulmonary gradient 8 (IQR 5-10) mm Hg, and PVR 2.1 (IQR 1.5-2.9) Wood units. Overall mortality was 35.7%, 12-month mortality was 23.7%, and the incidence of early RHF was 22.8%, which was significantly associated with overall mortality (log-rank HR 4.11, 95% CI 2.47-6.84; log-rank p < .0001). Pulmonary arterial elastance (Ea) was associated with overall mortality (HR 1.74, 95% CI 1.25-2.30; p < .001) independent of other non-hemodynamic risk factors. Ea values below a calculated cutoff represented a significantly reduced mortality risk (HR 0.38, 95% CI 0.19-0.76; p < .0001). PVR with the established cutoff of 3.0 WU was not significant. Ea was also significantly associated with 12-month mortality and RHF.


      Ea showed a strong impact on post-transplant mortality and RHF and should become part of the routine hemodynamic evaluation in HTx candidates.



      Ea (pulmonary arterial elastance), IMPACT (Index for Mortality Prediction After Cardiac Transplantation), INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support), PHM (Predicted heart mass), RHF (right heart failure), VRT (vasoreactivity testing)
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        • Khush KK
        • Hsich E
        • Potena L
        • et al.
        The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: thirty-eighth adult heart transplantation report - 2021; focus on recipient characteristics.
        J Heart Lung Transpl. 2021; 40: 1035-1049
        • Mehra MR
        • Canter CE
        • Hannan MM
        • et al.
        The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: a 10-year update.
        J Heart Lung transpl. 2016; 35: 1-23
        • Rivinius R
        • Helmschrott M
        • Ruhparwar A
        • et al.
        Elevated pre-transplant pulmonary vascular resistance is associated with early post-transplant atrial fibrillation and mortality.
        ESC Heart Fail. 2020; 7: 176-187
        • Vakil K
        • Duval S
        • Sharma A
        • et al.
        Impact of pre-transplant pulmonary hypertension on survival after heart transplantation: a UNOS registry analysis.
        Int J Cardiol. 2014; 176: 595-599
        • Chang PP
        • Longenecker JC
        • Wang NY
        • et al.
        Mild vs severe pulmonary hypertension before heart transplantation: different effects on posttransplantation pulmonary hypertension and mortality.
        J Heart Lung Transpl. 2005; 24: 998-1007
        • Hosenpud JD
        • Bennett LE
        • Keck BM
        • Boucek MM
        • Novick RJ
        The Registry of the International Society for Heart and Lung Transplantation: seventeenth official report-2000.
        J Heart Lung Transpl. 2000; 19: 909-931
        • Addonizio LJ
        • Gersony WM
        • Robbins RC
        • et al.
        Elevated pulmonary vascular resistance and cardiac transplantation.
        Circulation. 1987; 76: V52-V55
        • Weiss ES
        • Allen JG
        • Arnaoutakis GJ
        • et al.
        Creation of a quantitative recipient risk index for mortality prediction after cardiac transplantation (IMPACT).
        Ann Thorac Surg. 2011; 92 (discussion 21-2): 914-921
        • Coutance G
        • Bonnet G
        • Kransdorf EP
        • et al.
        Development and validation of specific post-transplant risk scores according to the circulatory support status at transplant: a UNOS cohort analysis.
        J Heart Lung Transpl. 2021; 40: 1235-1246
        • Smits JM
        • de Vries E
        • De Pauw M
        • et al.
        Is it time for a cardiac allocation score? First results from the Eurotransplant pilot study on a survival benefit-based heart allocation.
        J Heart Lung Transpl. 2013; 32: 873-880
        • Maron BA
        • Kovacs G
        • Vaidya A
        • et al.
        Cardiopulmonary hemodynamics in pulmonary hypertension and heart failure: JACC review topic of the week.
        J Am Coll Cardiol. 2020; 76: 2671-2681
        • Maron BA
        • Brittan EL
        • Hess E
        • et al.
        Pulmonary vascular resistance and clinical outcomes in patients with pulmonary hypertension: a retrospective cohort study.
        Lancet Respir Med. 2020;
        • Tampakakis E
        • Shah SJ
        • Borlaug BA
        • et al.
        Pulmonary effective arterial elastance as a measure of right ventricular afterload and its prognostic value in pulmonary hypertension due to left heart disease.
        Circ Heart Fail. 2018; 11e004436
        • Lund LH
        • Edwards LB
        • Kucheryavaya AY
        • et al.
        The Registry of the International Society for Heart and Lung Transplantation: thirty-second official adult heart transplantation report–2015; focus theme: early graft failure.
        J Heart Lung Transpl. 2015; 34: 1244-1254
        • Gong TA
        • Joseph SM
        • Lima B
        • et al.
        Donor predicted heart mass as predictor of primary graft dysfunction.
        J Heart Lung Transpl. 2018; 37: 826-835
        • Reed RM
        • Netzer G
        • Hunsicker L
        • et al.
        Cardiac size and sex-matching in heart transplantation: size matters in matters of sex and the heart.
        JACC Heart Fail. 2014; 2: 73-83
      1. Intermacs AE-definitions-final-02-4-2016. Manual of operations version 50; 2016.

        • Hsu S
        • Fang JC
        • Borlaug BA
        Hemodynamics for the heart failure clinician: a state-of-the-art review.
        J Card Fail. 2022; 28: 133-148
        • Tello K
        • Richter MJ
        • Axmann J
        • et al.
        More on single-beat estimation of right ventriculoarterial coupling in pulmonary arterial hypertension.
        Am J Respir Crit Care Med. 2018; 198: 816-818
        • Kang G
        • Ha R
        • Banerjee D
        Pulmonary artery pulsatility index predicts right ventricular failure after left ventricular assist device implantation.
        J Heart Lung Transplant. 2016; 35: 67-73
        • Chemla D
        • Lau EM
        • Papelier Y
        • Attal P
        • Herve P
        Pulmonary vascular resistance and compliance relationship in pulmonary hypertension.
        Eur Respir J. 2015; 46: 1178-1189
        • Tedford RJ
        Determinants of right ventricular afterload (2013 Grover Conference series).
        Pulm Circ. 2014; 4: 211-219
        • Armstrong HF
        • Schulze PC
        • Kato TS
        • Bacchetta M
        • Thirapatarapong W
        • Bartels MN
        Right ventricular stroke work index as a negative predictor of mortality and initial hospital stay after lung transplantation.
        J Heart Lung Transplant. 2013; 32: 603-608
        • Saouti N
        • Westerhof N
        • Helderman F
        • et al.
        Right ventricular oscillatory power is a constant fraction of total power irrespective of pulmonary artery pressure.
        Am J Respir Crit Care Med. 2010; 182: 1315-1320
        • Lankhaar JW
        • Westerhof N
        • Faes TJ
        • et al.
        Pulmonary vascular resistance and compliance stay inversely related during treatment of pulmonary hypertension.
        Eur Heart J. 2008; 29: 1688-1695
        • Tedford RJ
        • Hsu S
        • Kass DA
        Letter by Tedford et al Regarding Article, Effective arterial elastance in the pulmonary arterial circulation: derivation, assumptions, and clinical applications.
        Circ Heart Fail. 2020; 13e007081
        • Aleksova N
        • Alba AC
        • Molinero VM
        • et al.
        Risk prediction models for survival after heart transplantation: a systematic review.
        Am J Transpl. 2020; 20: 1137-1151
        • Hsich EM
        • Blackstone EH
        • Thuita LW
        • et al.
        Heart transplantation: an in-depth survival analysis.
        JACC Heart Fail. 2020; 8: 557-568
        • Lim HS
        • Hsich E
        • Shah KB
        ISHLT Position Statement on the role of right heart catheterization in the management of heart transplant recipients.
        J Heart Lung Transpl. 2018;
        • Wright SP
        • Groves L
        • Vishram-Nielsen JKK
        • et al.
        Elevated pulmonary arterial elastance and right ventricular uncoupling are associated with greater mortality in advanced heart failure.
        J Heart Lung Transpl. 2020; 39: 657-665
        • Muslem R
        • Ong CS
        • Tomashitis B
        • et al.
        Pulmonary arterial elastance and INTERMACS-defined right heart failure following left ventricular assist device.
        Circ Heart Fail. 2019; 12e005923
        • Hsi B
        • Joseph D
        • Trachtenberg B
        • et al.
        Degree of change in right ventricular adaptation measures during axillary Impella support informs risk stratification for early, severe right heart failure following durable LVAD implantation.
        J Heart Lung Transpl. 2022; 41: 279-282
        • Bellettini M
        • Frea S
        • Pidello S
        • et al.
        Pretransplant right ventricular dysfunction is associated with increased mortality after heart transplantation: a hard inheritance to overcome.
        J Card Fail. 2021;
        • Tampakakis E
        In search of markers of pulmonary vascular remodelling in pulmonary hypertension due to left heart disease.
        Eur J Heart Fail. 2018; 20: 735-737
        • Kremer N
        • Rako Z
        • Douschan P
        • et al.
        Unmasking right ventricular-arterial uncoupling during fluid challenge in pulmonary hypertension.
        J Heart Lung Transpl. 2022; 41: 345-355
        • Zern EK
        • Cheng S
        • Wolfson AM
        • et al.
        Angiotensin receptor-neprilysin inhibitor therapy reverses pulmonary hypertension in end-stage heart failure patients awaiting transplantation.
        Circ Heart Fail. 2020; 13e006696
        • Selim AM
        • Wadhwani L
        • Burdorf A
        • Raichlin E
        • Lowes B
        • Zolty R
        Left ventricular assist devices in pulmonary hypertension group 2 with significantly elevated pulmonary vascular resistance: a bridge to cure.
        Heart Lung Circ. 2019; 28: 946-952
        • Kobashigawa J
        • Zuckermann A
        • Macdonald P
        • et al.
        Report from a consensus conference on primary graft dysfunction after cardiac transplantation.
        J Heart Lung Transpl. 2014; 33: 327-340