Cardiac transplant recipients with preoperative pulmonary hypertension. Evolution of pulmonary hemodynamics and surgical options.

Among 48 consecutive patients with pretransplant pulmonary vascular resistance (PVR) greater than 4 Wood units, 38 patients underwent orthotopic heart replacement (OHT), and the remaining 10 received a graft in a heterotopic position (HHT). The OHT recipients were smaller (63 vs. 73 kg, p less than 0.05) and received a larger donor heart (donor-recipient, 109% vs. 79%, p less than 0.001) with a shorter graft ischemic time (108 vs. 139 minutes, p less than 0.05) than HHT recipients, reflecting patient selection and surgical complexity. Comparison between the hospital survivors and nonsurvivors identified the selection of HHT and graft ischemic time in excess of 150 minutes as potent risk factors. Immediately after transplantation, pulmonary artery (PA) pressures dropped to almost one half of preoperative values regardless of the mode of transplantation. Within the next 24 hours, however, the OHT group required lower doses of inotropes, had lower left atrial pressure (12 vs. 16 mm Hg, p less than 0.05), and were more frequently extubated (58% vs. 10%, p less than 0.01). Catheterization at 10 days revealed a doubled cardiac index and a dramatic reduction in PVR for both groups. The higher the preoperative PVR value, the more substantial the reduction observed, resulting in normalization of PVR for all survivors. The incidence of early graft failure was similar between the groups, but HHT recipients frequently developed pulmonary complications and infection, resulting in a 30% hospital survival in contrast to 71% in OHT recipients (p less than 0.05). The results suggest that transplant candidates with pulmonary hypertension might better be treated by OHT with an oversized, on-site, viable donor heart than by HHT.