Hemodynamic Recovery after Heart Transplantation.

The hemodynamic pattern of normal myocardial recovery after cardiac transplantation has not been previously described and the evidence for managing inotropes in this context is lacking.1Costanzo MR Dipchand A Starling R et al.International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients.J Heart Lung Transplant. 2010; 29: 914-956Abstract Full Text Full Text PDF PubMed Scopus (1036) Google Scholar, 2Schumacher KR Gajarski RJ. Postoperative care of the transplanted patient.Curr Cardiol Rev. 2011; 7: 110-122Crossref PubMed Scopus (12) Google Scholar Postoperative weaning of inotropic medications after heart transplant remains controversial. We examined hemodynamics and use of inotropic medication in this setting and hypothesized that a predictable nadir in cardiac function would occur during the first 5 days after transplantation. We performed a single-center retrospective observational study including 62 adult patients after cardiac transplantation. Patients undergoing multiorgan transplants, on postoperative mechanical support, and those who died within 5 days postoperatively were excluded. Statistical endpoints included cardiac index (CI), pulmonary artery pulsatility index (PAPi), and inotrope score at regular intervals.3Kang G Ha R Banerjee D. Pulmonary artery pulsatility index predicts right ventricular failure after left ventricular assist device implantation [published correction appears in J Heart Lung Transplant 2017;36:1272].J Heart Lung Transplant. 2016; 35: 67-73Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar Inotrope score is a validated composite of all continuous inotrope infusions reflecting the total dose administered.4Yamazaki Y Oba K Matsui Y et al.Vasoactive-inotropic score as a predictor of morbidity and mortality in adults after cardiac surgery with cardiopulmonary bypass.J Anesth. 2018; 32: 167-173Crossref PubMed Scopus (56) Google Scholar The median hours of CI and PAPi nadirs were determined. Baseline demographics and preoperative clinical conditions of the population are depicted in Table 1. The mean CI nadir was 2.5 ± 0.6 L/min/m2 compared with the overall mean CI of 3.1 ± 0.8 L/min/m2 of all patients over the 5-day period. The mean hour of cardiac index nadir after heart transplant was at hour 40 ± 21. The mean PAPi nadir was 0.6 ± 0.4 compared with the mean PAPi of 1.5 ± 0.8 of all patients over the 5-day period. The mean hour of PAPi nadir after transplant was hour 39 ± 26. For the aggregate population, there were no subsequent time points that were significantly different from the initial postcardiopulmonary bypass values for CI, PAPi, or inotrope score in the 5-day postoperative period. For individual patients, the median time point for postoperative CI nadir was hour 40 and the median time point for postoperative PAPi nadir was hour 36.Table 1Baseline CharacteristicsN62DemographicsAge (SD)54 ± 10Female17 (27%)Race White29 (47%) African American29 (47%) Hispanic3 (5%) Other1 (1%)Pretransplant Conditions Outpatient26 (42%) Inotrope infusion32 (52%) Intra-aortic balloon pump12 (19%) Left ventricular assist device32 (52%) VA ECMO3 (5%)Abbreviations: VA ECMO, venoarterial extracorporeal membrane oxygenation; SD, standard deviation. Open table in a new tab Table 2Population CI and PAPi DataCI Characteristics (n = 57) Mean CI (L/min/m2)3.1 ± 0.8 Mean CI nadir (L/min/m2)2.5 ± 0.6 Mean time of cardiac nadir (h)40 ± 22PAPi Characteristics (n = 58) Mean PAPi1.5 ± 0.8 Mean PAPI nadir0.6 ± 0.4 Mean time of PAPi nadir (h)39 ± 26Abbreviations: CI, cardiac index; PAPi, pulmonary artery pulsatility index. Open table in a new tab Abbreviations: VA ECMO, venoarterial extracorporeal membrane oxygenation; SD, standard deviation. Abbreviations: CI, cardiac index; PAPi, pulmonary artery pulsatility index. The current study was limited owing to its retrospective design, low sample size, exclusion criteria, and the emprical use of multiple inotrope medications before any documented assessments of myocardial function. Some vital signs and inotrope dosing documentation were charted at irregular intervals in the postoperative period. These limitations were mitigated through data collection at ±2 hours surrounding the targeted time point over the 5-day postoperative period if data was not available. Additionally, pulmonary artery catheter data was often unavailable for the entire 5-day period either owing to catheter failure (n = 1) or to patients no longer warranting invasive monitoring (n = 15). Given that these catheters are routinely removed for patients who are doing well, this has likely resulted in selection bias near the end of the study period (ie, CI and PAPi values of the patients doing the best would not have been captured). None.