[Impact of pulmonary hypertension on early hemodynamics after orthotopic heart transplantation].

OBJECTIVE

To determine the influence of normal pulmonary artery pressure, and mild to moderate and severe pulmonary hypertension on the early hemodynamics, morbidity, and mortality after orthotopic heart transplantations.

METHODS

Sixty-seven heart disease patients, 54 males and 13 females, aged (46.4 +/- 14.6), including ischemic heart diseases (n = 16), myocardiopathy (n = 43), and other heart diseases (n = 8), underwent orthotopic heart transplantation. Before and after transplantation routine right heart catheterization was conducted. According to the preoperative pulmonary arterial pressure the patients were divided into 3 groups: Group I (n = 15) without pulmonary hypertension (PH) with the pulmonary vascular resistance (PVR) < or = 2.5 Wood's units; Group II (n = 42) with mild to moderate PH with the PVR between 2.5 and 5.0 Wood's units; and Group III (n = 10) with severe PH with the PVR > or = 5.0 Wood's units. Heart rate (HR), mean artery pressure (MAP), central venous pressure (CVP), mean pulmonary artery pressure (MPAP), pulmonary artery wedge pressure (PAWP), PVR, cardiac output index (CI), and mixed venous oxygen saturation (S(V)O(2)) were measured preoperatively, immediately and 12, 24, and 48 hours postoperatively. 1, 3, and 7 days, and 1 and 3 months post-operatively echocardiography was conducted to measure the left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (EF), mitral valvular regurgitation (MVR), and tricuspid valvular regurgitation (TVR). Postoperative complications and mortality were recorded.

RESULTS

The 30-day mortality was zero in all 3 groups. The cardiovascular support used for weaning CPB and postoperative period included dopamine, ephedrine and isoproterenol. In addition, nitroglycerin, NO and iloprost were administered for pulmonary artery vasodilation if the pulmonary artery pressure was higher than 45 mm Hg. The EF value of Group III was significantly lower compared with group (P < 0.05). Before the heart transplantation, 52 patients (86%) had mild to severe PH, of which 10 patients (27%) had severe PH. The patients of Group III had longer CPB time and tracheal intubation time in comparison with the patients of Group I (P < 0.05). Postoperatively 6 patients, 1 in Group I, 2 in Group II, and 3 in Group III, had acute right ventricular failure and 3 patients, 1 in Group II and 2 in Group III, had renal failure. Basiliximab, cyclosporine A, mycophenolate mofetil, and methylprednisolone were administered for immunosuppressive treatment perioperatively.

CONCLUSION

The patients with severe PH pre-operatively have significantly lower pulmonary resistance and pressure, and have more complications, such as acute right heart failure, post-operatively. Active treatment with cardiac stimulant and diuretics is helpful. Smooth anesthetic induction and maintenance, peri-operative stable hemodynamic managements, especially the protection of right ventricle function for the first 2 weeks after the transplantation, myocardial protection of donor heart, and immunosuppressive regimen all play important roles for successive heart transplantation.