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Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

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Front. Med.    2023, Vol. 17 Issue (3) : 527-533    https://doi.org/10.1007/s11684-022-0967-5
RESEARCH ARTICLE
The clinical impact of tricuspid regurgitation in patients with a biatrial orthotopic heart transplant
Kevin M. Veen1, Grigorios Papageorgiou2, Casper F. Zijderhand1, Mostafa M. Mokhles1, Jasper J. Brugts3, Olivier C. Manintveld3, Alina A. Constantinescu3, Jos A. Bekkers1, Johanna J.M. Takkenberg1, Ad J.J.C. Bogers1, Kadir Caliskan3()
1. Department of Cardiothoracic Surgery, Erasmus MC, 3000 CA Rotterdam, The Netherlands
2. Department of Biostatistics, Erasmus MC, 3000 CA Rotterdam, The Netherlands
3. Department of Cardiology, Erasmus MC, 3000 CA Rotterdam, The Netherlands
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Abstract

In this study, we aim to elucidate the clinical impact and long-term course of tricuspid regurgitation (TR), taking into account its dynamic nature, after biatrial orthotopic heart transplant (OHT). All consecutive adult patients undergoing biatrial OHT (1984−2017) with an available follow-up echocardiogram were included. Mixed-models were used to model the evolution of TR. The mixed-model was inserted into a Cox model in order to address the association of the dynamic TR with mortality. In total, 572 patients were included (median age: 50 years, males: 74.9%). Approximately 32% of patients had moderate-to-severe TR immediately after surgery. However, this declined to 11% on 5 years and 9% on 10 years after surgery, adjusted for survival bias. Pre-implant mechanical support was associated with less TR during follow-up, whereas concurrent LV dysfunction was significantly associated with more TR during follow-up. Survival at 1, 5, 10, 20 years was 97% ± 1%, 88% ± 1%, 66% ± 2% and 23% ± 2%, respectively. The presence of moderate-to-severe TR during follow-up was associated with higher mortality (HR: 1.07, 95% CI (1.02–1.12), p = 0.006). The course of TR was positively correlated with the course of creatinine (R = 0.45). TR during follow-up is significantly associated with higher mortality and worse renal function. Nevertheless, probability of TR is the highest immediately after OHT and decreases thereafter. Therefore, it may be reasonable to refrain from surgical intervention for TR during earlier phase after OHT.
Keywords orthotopic heart transplant      tricuspid regurgitation      clinical impact      biatrial heart transplantation     
Corresponding Author(s): Kadir Caliskan   
Just Accepted Date: 07 December 2022   Online First Date: 30 March 2023    Issue Date: 28 July 2023
 Cite this article:   
Kevin M. Veen,Grigorios Papageorgiou,Casper F. Zijderhand, et al. The clinical impact of tricuspid regurgitation in patients with a biatrial orthotopic heart transplant[J]. Front. Med., 2023, 17(3): 527-533.
 URL:  
https://academic.hep.com.cn/fmd/EN/10.1007/s11684-022-0967-5
https://academic.hep.com.cn/fmd/EN/Y2023/V17/I3/527
CharacteristicsN = 572
Recipient age (median, IQR)50.2 (41.9, 56.3)
Donor age (median, IQR)33.0 (22.0, 44.0)
Receiver female sex (n,%)143 (25.1)
Donor female sex (n,%)277 (49.0)
Primary diagnosis (n,%)
Non ischemic275 (49.4)
Ischemic254 (45.6)
Other28 (5.0)
Creatinine (median, IQR)114.0 (93.0, 136.0)
Immunosuppression (n,%)
Cyclosporine + azathioprine + prednisone70 (12.3)
Cyclo + MMF + prednisone32 (5.6)
Cyclosporine + prednisone150 (26.4)
Tacrolimus + prednisone121 (21.3)
tacrolimus + MMF21 (3.7)
Other175 (30.8)
Number of prior cardiac operations (n,%)
0415 (72.8)
1125 (21.9)
226 (4.6)
34 (0.7)
Urgency (n,%)
0370 (65.1)
199 (17.4)
293 (16.4)
36 (1.1)
Pre HTx diabetes (n,%)35 (6.4)
Pre HTx mechical assistance (%)
None517 (92.8)
LVAD33 (5.9)
ECMO2 (0.4)
IABP5 (0.9)
Ischemia time (median,IQR)170.0 (143.00, 203.0)
Rethoractomy (n,%)77 (13.5)
Dialysisa (%)94 (16.8)
Pacemakera (%)70 (12.5)
Number rejection first year 1(median (IQR))1.0 (1.0, 2.0)
Tab.1  Pre-, peri-, postoperative characteristics
Fig.1  The marginal probability of moderate-to-severe TR during follow-up for an average patient.
VariableOR95% CIP value
Intercept0.10(0.01, 1.35)0.090
Spline 1 of timea0.23(0.09, 0.56)< 0.001
Spline 2 of timea0.03(0.01, 0.13)< 0.001
Spline 3 of timea0.18(0.02, 1.22)0.080
Receiver age0.98(0.95, 1.01)0.138
Donor age1.02(0.99, 1.05)0.114
Receiver female sex0.77(0.36, 1.59)0.466
Donor female sex1.66(0.86, 3.18)0.130
Ischemia time0.96(0.89, 1.04)0.344
Cardiac reoperation0.99(0.56, 1.76)0.952
Urgency 1 vs. 01.40(0.56, 3.55)0.456
Urgency 2/3 vs. 00.63(0.27, 1.46)0.322
No mechanical assistance prior HTx6.29(1.47, 27.31)0.014
Pre HTx diabetes0.60(0.19, 1.94)0.394
Number rejection first year1.02(0.88, 1.19)0.742
Mildly impaired LV function vs. normalb1.73(1.32, 2.31)< 0.001
Moderately impaired LV function vs. normalb4.03(2.29, 7.18)< 0.001
Severely impaired LV function vs. normalb9.54(2.82, 38.46)< 0.001
Pacemakerb1.12(0.59, 2.07)0.718
Creatinine1.00(1.00, 1.01)0.374
Tab.2  Estimates of logistic mixed-model part of the joint model to predict moderate-to-severe TR over time
Fig.2  A Kaplan–Meier curve of overall survival.
VariableHR95% CIP value
Receiver age1.04(1.03, 1.06)< 0.001
Receiver female sex1.44(1.02, 2.03)0.046
Donor female sex1.05(0.78, 1.44)0.768
Ischemia time1.00(1.00, 1.01)0.064
Cardiac reoperation1.22(0.91, 1.6)0.174
Urgency1 vs. 00.90(0.61, 1.31)0.590
Urgency2 vs. 00.78(0.48, 1.22)0.270
Urgency3 vs. 012.26(2.32, 55.12)0.012
No mechanical assistance prior HTx0.75(0.28, 2.19)0.580
Donor age0.99(0.98, 1.01)0.372
Non-ischemic CMP vs. ischemic1.17(0.82, 1.66)0.364
Other diagnosis vs. ischemic1.15(0.55, 2.15)0.668
Pre HTx diabetes2.30(1.30, 3.80)< 0.001
Creatinine1.00(1.00, 1.00)0.096
Pacemakera1.00(0.64, 1.52)0.972
Dialysisa1.81(1.27, 2.50)0.002
Mod-sev TR1.07(1.02, 1.13)0.006
Tab.3  Estimates of the joint-model survival part
Fig.3  A dynamic plot of two patients (A and B). Patient A develops TR after 3 years and patient B does not develop TR after 3 years.
Fig.4  The predicted evolution of creatinine after HTx.
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