Purpose Some cardiac transplant patients develop restrictive physiology with normal systolic function. Most of this restrictive physiology may be due to cardiac allograft vasculopathy (CAV). These patients demonstrate recurrent fluid retention and heart failure symptoms due to low cardiac output from cardiac restriction, and the outcome is believed to be poor.
Methods To test this hypothesis, we reviewed 542 patients transplanted between 1994 and 2004 and identified 30 patients who exhibited restrictive physiology and 512 patients without (control group). Restrictive physiology was defined as symptomatic heart failure, normal left ventricular ejection fraction, an echo E to A velocity ratio > 2, shortened isovolumetric relaxation time (< 60 msec), shortened deceleration time (< 150 msec), or abnormal hemodynamic values (RA > 12, PCW > 25, CI < 2.0). Multivariate analysis was performed to assess the risk of restrictive physiology on 5-year survival.
Results Of the 30 patients with restrictive physiology, 15 were male, 17 had evidence for epicardial CAV, 19 had, on average, 2.4 episodes of rejection, and 10 patients had history of hemodynamic compromise rejection. Five-year survival was significantly lower in the restrictive physiology group compared with the control group (58% vs 84%, p < .001. Restrictive physiology conferred a 3.68-fold increase risk in mortality even after adjusting for age, gender, ischemic time, elevated PRA, presence of CAV, abnormal creatinine, and hypertension.
Conclusions Once heart transplant patients develop restrictive physiology, despite normal systolic function, outcomes appear to be poor. Newer or novel therapies to treat this condition and/or consideration for redo heart transplantation should be considered.
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