Steven J Kindel1, Yuk M Law2, Clifford Chin3, Michael Burch4, James K Kirklin5, David C Naftel5, Elizabeth Pruitt5, Michael P Carboni6, Anna Arens7, Andrew M Atz8, William J Dreyer9, William T Mahle10, Elfriede Pahl7. 1. Department of Pediatrics, Children's Hospital & Medical Center, University of Nebraska, Omaha, Nebraska. Electronic address: skindel@childrensomaha.org. 2. Department of Pediatrics, Children's Hospital & Regional Medical Center, University of Washington, Seattle, Washington. 3. Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital & Medical Center, University of Cincinnati, Cincinnati, Ohio. 4. Department of Pediatrics, Great Ormond Street Hospital, London, United Kingdom. 5. Department of Surgery, University of Alabama Birmingham, Birmingham, Alabama. 6. Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina. 7. Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois. 8. Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina. 9. Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas. 10. Department of Pediatrics, Sibley Heart Center, Children's Health Care of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
Abstract
BACKGROUND: Recent guidelines recommend assessment of systolic function and filling pressures to augment angiographic grading of cardiac allograft vasculopathy (CAV); however, no data exist on the utility of these guidelines. OBJECTIVES: The aims of this study were to evaluate whether the assessment of systolic and diastolic graft function, in addition to angiography, improves recognition of patients at high risk of graft loss and to assess the ability of adult filling-pressure thresholds to discriminate graft dysfunction in pediatric patients. METHODS: This study reviewed Pediatric Heart Transplant Study data from 1993 to 2009. Graft dysfunction was defined as significant systolic dysfunction (ejection fraction [EF] <45%) or the presence of restrictive hemodynamic features. Additional pediatric hemodynamic cutpoints of right atrial pressure (RAP) >12 mm Hg or pulmonary capillary wedge pressure (PCWP) >15 mm Hg were analyzed. RESULTS: In the study, 8,122 angiograms were performed in 3,120 patients, and 70% of patients had at least 1 angiogram. Angiographic incidence of CAV was 5%, 15%, and 28% at 2, 5, and 10 years, respectively, and most disease was mild. The presence of graft dysfunction identified patients at greater risk for graft loss even in children with mild angiographic vasculopathy (p < 0.0001). An RAP >12 mm Hg or a PCWP >15 mm Hg was sufficient to detect patients at high risk of graft loss even with mild angiographic disease. CONCLUSIONS: Patients with only mild angiographic CAV have significantly better outcomes than do patients with moderate or severe disease. The presence of an EF <45%, an RAP >12 mm Hg, or a PCWP >15 mm Hg identifies children at increased risk of graft loss even in the presence of only mild angiographic vasculopathy.
BACKGROUND: Recent guidelines recommend assessment of systolic function and filling pressures to augment angiographic grading of cardiac allograft vasculopathy (CAV); however, no data exist on the utility of these guidelines. OBJECTIVES: The aims of this study were to evaluate whether the assessment of systolic and diastolic graft function, in addition to angiography, improves recognition of patients at high risk of graft loss and to assess the ability of adult filling-pressure thresholds to discriminate graft dysfunction in pediatric patients. METHODS: This study reviewed Pediatric Heart Transplant Study data from 1993 to 2009. Graft dysfunction was defined as significant systolic dysfunction (ejection fraction [EF] <45%) or the presence of restrictive hemodynamic features. Additional pediatric hemodynamic cutpoints of right atrial pressure (RAP) >12 mm Hg or pulmonary capillary wedge pressure (PCWP) >15 mm Hg were analyzed. RESULTS: In the study, 8,122 angiograms were performed in 3,120 patients, and 70% of patients had at least 1 angiogram. Angiographic incidence of CAV was 5%, 15%, and 28% at 2, 5, and 10 years, respectively, and most disease was mild. The presence of graft dysfunction identified patients at greater risk for graft loss even in children with mild angiographic vasculopathy (p < 0.0001). An RAP >12 mm Hg or a PCWP >15 mm Hg was sufficient to detect patients at high risk of graft loss even with mild angiographic disease. CONCLUSIONS:Patients with only mild angiographic CAV have significantly better outcomes than do patients with moderate or severe disease. The presence of an EF <45%, an RAP >12 mm Hg, or a PCWP >15 mm Hg identifies children at increased risk of graft loss even in the presence of only mild angiographic vasculopathy.
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