Abstract 2411: The Importance of Right Ventricular Dysfunction in patients with Hemodynamically Compromising Rejection
Background: Hemodynamically compromising rejection (HCR) has been a major cause of mortality and morbidity following heart transplantation. Right ventricular (RV) dysfunction has been previously recognized as a major predictor of survival in patients with heart failure.
Hypothesis: We hypothesize that RV dysfunction is a major risk factor for survival or retransplantation in patients with HCR.
Methods: Medical records of 548 heart transplant patients followed at Stanford University between January 1998 and January 2007 were reviewed. HCR was defined as a rejection episode leading to hospitalization for heart failure or cardiogenic shock. Right ventricular dysfunction was defined by the presence of a right ventricular fractional area change lower than 25% and dilated inferior venae ( > 2.5 cm). Two independent investigators reviewed the echocardiograms. Univariate and multivariate analyses were performed to identify risk factors for death or retransplantation at 1 year.
Results: HCR occurred in 71 patients (12.9%). Death or retransplantation at one year occurred in 28 patients (39%). Univariate analysis identified non-cellular rejection (OR = 3.20, p = 0.021), the need for inotropic support (OR = 4.80, p = 0.007), severe right ventricular dysfunction (OR = 4.63, p = 0.006), left ventricular ejection fraction (OR = 0.941, p = 0.031) and acute renal failure (OR = 3.82, p = 0.010) as predictors of death or retransplantation at 1 year. Multivariate analysis identified severe right ventricular dysfunction (OR = 4.80, p = 0. 0.007) and the need for inotropic support (OR = 5.00 p = 0.009) as predictors of major events. The multivariate model included RV dysfunction, left ventricular dysfunction (LVEF < 30%), inotropic support and histological grade of rejection.
Conclusion: In the modern era of immunosuppression, HCR remains a major complication after heart transplantation. The presence of severe right ventricular dysfunction may improve risk stratification of patients with HCR. Non-cellular rejection was associated with more severe graft failure and an increased risk of death or retransplantation than cellular rejection.