RESTING HEMODYNAMICS AFTER TOTAL VERSUS STANDARD ORTHOTOPIC HEART-TRANSPLANTATION IN PATIENTS WITH HIGH PREOPERATIVE PULMONARY VASCULAR-RESISTANCE

Objective: Pretransplant pulmonary vascular resistance greater than or equal to 4 Wood-units predisposes to right ventricular failure after heart transplantation. Total orthotopic heart transplantation with bic aval and pulmonary Venous anastomoses offers synchronous contractions of the atria and a normal ventricular filling pattern, but requires lo nger ischemic time than standard orthotopic heart transplantation. To test if total orthotopic heart transplantation improves resting hemody namics in pts with high preoperative pulmonary Vascular resistance, we analyzed 65 pts with standard and 65 with total orthotopic heart tran splantation transplanted between 12/88 and 7/94. Of these, 18 with tot al and 15 with standard orthotopic heart transplantation had a preoper ative pulmonary vascular resistance greater than or equal to 4 Wood-un its. Methods: Right heart catheterization data were obtained at each e ndomyocardial biopsy. All data from biopsies at both 2 weeks and 1 yea r posttransplant that were free from humoral or greater than 1A cellul ar rejection (9 Versus 13 pts) were included in a two way ANOVA. Pts w ith postop pacemakers, atrial fib or beta-blocker therapy at the time of biopsy were excluded. Results: Ischemic time was different (172 +/- 44 versus 142 +/- 28 min, P = 0.03). Demographics, NYHA class, pre-TX hemodynamics, donor age and inotropes were similar. Cardiac output an d index were higher in the total orthotopic group at 2 weeks (6.5 +/- 1.7 versus 5.1 +/- 1.0 l/min; 3.4 +/- 0.9 versus 2.8 +/- 0.6 l/min per m(2)) and 1 year (7.1 +/- 2.0 versus 4.9 +/- 1.1 l/min, P = 0.002; 3. 6 +/- 1.1 versus 2.6 +/- 0.5 l/min per m(2), P = 0.009). Right atrial and pulmonary arterial mean pressure (mmHg) were lower with total orth otopic heart transplantation at 2 weeks (6 +/- 4 versus 9 +/- 5, P = 0 .04; 22 +/- 3 versus 25 +/- 7 P = 0.1) and 1 year (5 +/- 2 versus 7 +/ - 3, P = 0.02; 19 +/- 4 versus 25 +/- 7, P = 0.03). Pulmonary capillar y wedge pressure (mmHg) was borderline nonsignificant (11 +/- 4 versus 13 +/- 7 at 2 weeks, 8 +/- 3 versus 14 +/- 5 at 1 year, P = 0.055), a s well as pulmonary vascular resistance (1.9 +/- 1 versus 2.5 +/- 1 at 2 weeks, 1.5 +/- 0.6 versus 2.7 +/- 1.7 WU at 1 year, P = 0.051). Con clusions: Total orthotopic heart transplantation improves cardiac outp ut and index in pts with high preoperative pulmonary vacular resistanc e. There is a lower mean RA and PA pressure perhaps due to less tricus pid and mitral regurgitation. In view of the frequently observed restr ictive filling pattern after cardiac transplantation, total orthotopic heart transplantation can be beneficial until this pattern has subsid ed by preserving atrioventricular synchrony and offering better atrial transport. (C) 1997 Elsevier Science B.V.