Impact of pre-transplant pulmonary hypertension on survival after heart transplantation: A UNOS registry analysis Kairav Vakil a, ⁎, Sue Duval a , Alok Sharma a , Selcuk Adabag b , Kashan Syed Abidi a , Ziad Taimeh a , Monica Colvin-Adams a a Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA b Division of Epidemiology and Community Health, School of Public Health, University of Minnesota and Veterans Affairs Medical Center, Minneapolis, MN, USA abstract article info Article history: Received 22 March 2014 Received in revised form 29 July 2014 Accepted 11 August 2014 Available online 16 August 2014 Keywords: Pulmonary hypertension Heart transplantation Mortality Introduction: Severe pre-transplant pulmonary hypertension (PH) has been associated with adverse short-term clinical outcomes after heart transplantation in relatively small single-center studies. The impact of pre- transplant PH on long-term survival after heart transplantation has not been examined in a large, multi-center cohort. Methods: Adults (≥18 years) who underwent first time heart transplantation in the United States between 1987 and 2012 were retrospectively identified from the United Network for Organ Sharing registry. Pre-transplant PH was classified as mild, moderate, or severe based on pulmonary vascular resistance (PVR), trans-pulmonary gradient (TPG), and pulmonary artery (PA) mean pressure. Primary outcome was all-cause mortality. Results: Data from 26,649 heart transplant recipients (mean age 52 ± 12 years; 76% male; 76% Caucasian) were analyzed. During a mean follow-up of 5.7 ± 4.8 years, there were 10,334 (39%) deaths. Pre-transplant PH (PVR ≥ 2.5 WU) was a significant predictor of mortality (hazard ratio 1.10, 95% confidence interval 1.05–1.14, p b 0.0001) in multivariable analysis. However, the severity of pre-transplant PH (mild/moderate vs. severe) did not affect short or long-term survival. Similarly, even in patients who were supported with either a left ventricular assist device or a total artificial heart prior to transplant, severe pre-transplant PH was not associated with worse survival when compared to patients with mild/moderate pre-transplant PH. Conclusion: Pre-transplant PH (PVR ≥ 2.5 WU) is associated with a modest increase in mortality when compared to patients without pre-transplant PH. However, the severity of pre-transplant PH, assessed by PVR, TPG, or mean PA pressure, is not a discriminating factor for poor survival in patients listed for heart transplantation. © 2014 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Heart transplantation is the mainstay of treatment for patients with end-stage heart failure. Pulmonary hypertension (PH) is commonly present in heart failure patients and portends adverse clinical outcomes irrespective of its etiology [1–3]. Presence of pre-transplant PH in heart organ recipients increases the risk of post-transplant PH and deteriora- tion in right ventricular function in the donor heart. Cumulatively, these effects are associated with adverse post-operative outcomes [4,5]. As such, the International Society of Heart and Lung Transplantation (ISHLT) guidelines consider the presence of severe pre-transplant PH, defined as pulmonary vascular resistance (PVR) N 5 Wood units (WU) or trans-pulmonary gradient (TPG) N 16–20 mm Hg, as a relative con- traindication for heart transplantation [6]. Results from prior studies addressing the impact of pre-transplant PH on post-transplant survival have been inconsistent [4,7–14]. Further, relatively small single-center studies have shown that even milder degrees of pre-transplant PH may adversely influence survival after heart transplantation [4,8]. However, these studies were limited by rel- atively small sample size and short follow-up. Whether pre-transplant PH is associated with detrimental long-term survival in heart transplant recipients has not been examined in a large, multicenter cohort. As such, this study aims to examine the impact of pre-transplant PH on survival after heart transplantation in the largest multicenter prospective registry of heart transplant recipients in the United States (US). International Journal of Cardiology 176 (2014) 595–599 ⁎ Corresponding author at: University of Minnesota, Mayo Mail Code 508, 420 Delaware Street SE, Minneapolis, MN 55455, USA. Tel.: +1 612 656 2451; fax: +1 612 626 4411. E-mail address: vakil012@umn.edu (K. Vakil). Table 1 Classification of pulmonary hypertension severity based on different definitions. Definition None Mild Moderate Severe Pulmonary vascular resistance (Wood units) b2.5 2.5–3.4 3.5–4.9 ≥5.0 Trans-pulmonary gradient (mm Hg) b13 13–16 17–19 ≥20 Mean pulmonary artery pressure (mm Hg) b25 25–34 35–44 ≥45 http://dx.doi.org/10.1016/j.ijcard.2014.08.072 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard