Acute right ventricular failure after pediatric cardiac transplant: predictors and long-term outcome in current era of transplantation medicine

Abstract

Objectives: To identify pretransplant factors associated with postprocedural right ventricular failure and the relationship between right ventricular failure and long-term survival in children.

Methods: Records were reviewed for children having heart transplantation from 2000 to 2006.

Results: Right ventricular failure was identified by clinical and echocardiographic parameters in 33/129 (25%) recipients: dilated cardiomyopathy in 14/90 (15%), congenital heart disease in 11/27 (41%), and restrictive cardiomyopathy in 8/12 (66%). In 9 of 12 (75%), known elevated (reactive) pulmonary vascular resistance progressed to right ventricular failure. In a further 23/117 (20%) recipients, pulmonary vascular resistance within predefined acceptable range progressed to right ventricular failure. Multiple logistic regression analyses indicated elevated pulmonary vascular resistance (odds ratio 12.30; 95% confidence interval 2.73, 55.32; P = .001) and primary diagnosis, restrictive cardiomyopathy (odds ratio 9.21; 95% confidence interval 2.07, 41.12; P = .004), and congenital heart disease (odds ratio 4.07; 95% confidence interval 1.36, 12.19; P = .012) were strongly associated with right ventricular failure, but duration of heart failure, pretransplant mechanical support, donor status, and ischemic times were not. Treatment included inhaled nitric oxide in 28 (84%), mechanical support in 10 (31%), hemofiltration in 13 (40%), and retransplantation in 2. A Cox multiple regression model including: primary diagnosis, right ventricular failure, and elevated pulmonary vascular resistance indicated that only the latter was independently linked with eventual mortality (hazards ratio 5.45; 95% confidence interval 1.36, 21.96; P = .017).

Conclusions: Primary diagnosis and pretransplant elevated reactive pulmonary vascular resistance are both linked to the evolution of right ventricular failure. Pulmonary vascular resistance assessment in end-stage heart failure is challenging; therefore, avoidance of right ventricular failure may not always be possible. Aggressive early treatment may mitigate the effects of right ventricular failure: pretransplant elevated pulmonary vascular resistance was independently associated with long-term survival, but right ventricular failure was not.