ABSTRACT
Introduction:
After heart transplantation (HTx), some patients continue to experience disproportionately high mortality.
Objectives:
To investigate which clinical variables are associated with survival after HTx.
Methods:
Retrospective, single-center cohort study with 55 patients undergoing HTx from May 2019 to April 2023.
Results:
Logistic regression identified, as variables associated with death, the increase in creatinine in the immediate postoperative period (POI) (p = 0.0067), pulmonary vascular resistance (RVP) (p = 0.0185) and pulmonary artery systolic pressure (PSAP) before HTx (p = 0.0415). When constructing the ROC curve (receiver operating characteristic curve) with the delta of the increase in creatinine in the first 24 postoperative hours, the cutoff point was 0.35 mg/dL, the sensitivity was 0.76, and the specificity was 0. 90. In the ROC curve for PVR, the cutoff point was 2.23 Woods units (WU), with sensitivity of 0.79 and specificity of 0.72. In the ROC curve for PSAP, the cutoff point was 40.50 mmHg, with a sensitivity of 0.89 and a specificity of 0.86.
Conclusion:
An increase in creatinine to a value greater than or equal to 0.35 mg/dL in the first 24 hours, PSAP with values greater than 40.5 mmHg and an increase in RVP to a value above 2.23 WU are associated with increased rates of hospital mortality after HTx.
Descriptors
Heart Transplantation; Creatinine; Hypertension Pulmonary; Heart Failure; Mortality
RESUMO
Introdução:
Após o transplante cardíaco (TxC), alguns pacientes continuam a apresentar mortalidade desproporcionalmente alta.
Objetivos:
Investigar quais variáveis clínicas estão associadas à sobrevida após o TxC.
Métodos:
Estudo do tipo coorte retrospectivo, unicêntrico, com 55 pacientes submetidos a TxC no período de maio de 2019 a abril de 2023.
Resultados:
A regressão logística identificou, como variáveis associadas ao óbito, o aumento da creatinina no pós-operatório imediato (POI) (p = 0,0067), a resistência vascular pulmonar (RVP) (p = 0,0185) e a pressão sistólica da artéria pulmonar (PSAP) prévios ao TxC (p = 0,0415). Ao construir a curva ROC (receiver operating characteristic curve) com o delta do aumento da creatinina nas primeiras 24 horas do pós-operatório, o ponto de corte foi de 0.35 mg/dL, a sensibilidade de 0,76 e a especificidade de 0,90. Na curva ROC para a RVP, o ponto de corte foi de 2,23 unidades Woods (WU), com sensibilidade de 0,79 e especificidade de 0,72. Na curva ROC para a PSAP, o ponto de corte foi de 40,50 mmHg, com sensibilidade de 0,89 e especificidade de 0,86.
Conclusão:
Aumento da creatinina para valor maior ou igual a 0,35 mg/dL nas primeiras 24 horas, PSAP com valores superiores a 40,5 mmHg e aumento da RVP para valor acima de 2,23 WU estão associados ao aumento das taxas de mortalidade hospitalar após o TxC.
Descritores
Transplante de Coração; Creatinina; Hipertensão Pulmonar; Insuficiência Cardíaca; Mortalidade
INTRODUCTION
Cardiovascular diseases are the leading cause of death in Brazil, with emphasis on heart failure (HF), which is the leading cause of hospitalizations. Despite advances in the treatment of this condition, the prognosis remains unfavorable, resulting in high mortality rates11 Almeida DE, Pereira-Barreto AC, Forestiero FJ, Nakamuta JS, Bichels A. A carga médica da insuficiência cardíaca: um delineamento comparativo com o câncer no Brasil. Int J Cardiovasc Sci 2022;35(4):514-20. https://doi.org/10.36660/ijcs.20200382
https://doi.org/10.36660/ijcs.20200382...
,22 Brasil. Ministério da Saúde. DATASUS. Mortalidade. Brasília, 2016 [acesso em 12 Jul 2023]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/cnv/obt10uf.def
http://tabnet.datasus.gov.br/cgi/tabcgi....
. Heart transplantation (CTx) is one of the treatments of choice in cases of advanced HF33 Carvalho T, Milani M, Ferraz AS, Silveira ADD, Herdy AH, Hossri CAC, et al. Brazilian Cardiovascular Rehabilitation Guideline – 2020. Arq Bras Cardiol 2020;114(5):943-87. Erratum in: Arq Bras Cardiol 2021;117(2):423. https://doi.org/10.36660/abc.20200407
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TxC is a surgical procedure for replacing a sick heart with a healthy heart from a donor, enabling the normalization of the patient’s hemodynamics44 Shah KS, Kittleson MM, Kobashigawa JA. Updates on heart transplantation. Curr Heart Fail Rep 2019;16(5):150-6. https://doi.org/10.1007/s11897-019-00432-3
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5 Bacal F, Marcondes-Braga FG, Rohde LEP, Xavier Júnior JL, Brito FS, Moura LAZ, et al. 3ª Diretriz Brasileira de Transplante Cardíaco. Arq Bras Cardiol 2018;111(2):230-89. https://doi.org/10.5935/abc.20180153
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-66 Reich HJ, Kobashigawa JA, Aintablian T, Ramzy D, Kittleson MM, Esmailian F. Effects of older donor age and cold ischemic time on long-term outcomes of heart transplantation. Tex Heart Inst J 2018;45(1):17-22. https://doi.org/10.14503/THIJ-16-6178
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Surgery is a high-risk procedure, and understanding the factors influencing patient survival is extremely important for optimizing the clinical support offered to patients77 Fuchs M, Schibilsky D, Zeh W, Berchtold-Herz M, Beyersdorf F, Siepe M. Does the heart transplant have a future? Eur J Cardiothorac Surg 2019;55 Suppl 1:i38-i48. https://doi.org/10.1093/ejcts/ezz107
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Even after TxC, the patient may continue to present symptoms related to HF, such as reduced functional capacity, requiring early physiotherapeutic follow-up88 Conceição TMA, Gonzáles AI, Figueiredo FCXS, Vieira DSR, Bündchen DC. Critérios de segurança para iniciar a mobilização precoce em unidades de terapia intensiva. Revisão sistemática. Rev Bras Ter Intensiva 2017;29(4)509-19. https://doi.org/10.5935/0103-507X.20170076
https://doi.org/10.5935/0103-507X.201700...
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Cardiac rehabilitation (CR) is divided into four phases: phase I, which occurs during hospitalization; phase II, carried out on an outpatient basis starting shortly after hospital discharge; and phases III and IV, which aim to maintain the gains obtained in rehabilitation99 Chagas AM, Alves YM, Alencar AMC. Reabilitação cardíaca fase I: uma revisão sistemática. ASSOBRAFIR Ciência 2016;7(3)51-60.. Phase I begins with gaining physical fitness, emphasizing functional activities, and consists of aerobic and resistance exercises for large muscle groups99 Chagas AM, Alves YM, Alencar AMC. Reabilitação cardíaca fase I: uma revisão sistemática. ASSOBRAFIR Ciência 2016;7(3)51-60.. CR is an excellent strategy to improve the health recovery of transplant patients, providing greater independence and reducing symptoms of anxiety and depression33 Carvalho T, Milani M, Ferraz AS, Silveira ADD, Herdy AH, Hossri CAC, et al. Brazilian Cardiovascular Rehabilitation Guideline – 2020. Arq Bras Cardiol 2020;114(5):943-87. Erratum in: Arq Bras Cardiol 2021;117(2):423. https://doi.org/10.36660/abc.20200407
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,1010 Tackmann E, Dettmer S. Health-related quality of life in adult heart-transplant recipients-a systematic review. Herz 2020;45(5):475-82. https://doi.org/10.1007/s00059-018-4745-8
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,1111 Rolid K, Andreassen AK, Yardley M, Gude E, Bjørkelund E, Authen AR, et al. High-intensity interval training and health-related quality of life in de novo heart transplant recipients – Results from a randomized controlled trial. Health Qual Life Outcomes 2020;18(1):283. https://doi.org/10.1186/s12955-020-01536-4
https://doi.org/10.1186/s12955-020-01536...
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This study aimed to investigate which clinical variables are associated with early mortality, aiming to improve clinical outcomes in this patient population.
METHODS
This article is a retrospective, single-center cohort study based on the analysis of electronic medical records and databases of all patients undergoing TxC surgery at the Hospital das Clínicas of the Faculdade de Medicina de Botucatu (HCFMB) from May 2019 to April 2023. The TxC service began its activities in May 2019, and this study presents data from the first 55 patients who underwent TxC at this hospital institution.
Epidemiological, clinical and anthropometric data, laboratory tests from the patient’s hospitalization after TxC, and information about CR in the ICU were collected.
The Barthel Index (BI) was used to evaluate functional capacity, measuring the level of assistance that a person requires in 10 activities: feeding, personal hygiene, clothing, urine and feces control, bathroom use, bed/chair transfer, mobility and ability to climb stairs. The score ranges from 0 to 100, with higher scores indicating greater functional independence1212 de Paula GV, da Silva TR, de Souza JT, Luvizutto GJ, Bazan SGZ, Modolo GP, et al. Effect of ankle-foot orthosis on functional mobility and dynamic balance of patients after stroke: study protocol for a randomized controlled clinical trial. Medicine (Baltimore) 2019;98(39):e17317. . https://doi.org/10.1097/MD.0000000000017317,1313 Liu F, Tsang RC, Zhou J, Zhou M, Zha F, Long J, et al. Relationship of Barthel Index and its Short Form with the Modified Rankin Scale in acute stroke patients. J Stroke Cerebrovasc Dis 2020;29(9)105033. https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105033
https://doi.org/10.1016/j.jstrokecerebro...
. The physiotherapy team applies the BI in an interview format to all patients admitted to the HCFMB intensive care unit (ICU).
Statistical analysis
Categorical variables were represented as absolute and relative frequencies, and continuous variables as mean ± standard deviation (SD). The Kolmogorov-Smirnov (KS) test verified the normality of the distribution. Associations between categorized variables and death were obtained using the chi-square test; for continuous variables with symmetrical distribution, the Student’s t-test was applied, while for those with asymmetrical distribution, an adjustment was made using gamma distribution. For discrete variables, the comparison was made using Poisson distribution adjustment. A logistic regression model was adjusted, considering the other explanatory variables for the outcome of death during hospitalization.
Subsequently, a receiver operating characteristic curve (ROC) analysis was performed using risk factors as predictors of the outcome of death during hospitalization. Analysis was conducted using Pearson correlations between length of stay after heart transplantation and physiotherapy variables and functionality with survivors after surgery. A p < 0.05 was set for statistical significance. The analyses were conducted using SAS 9.4 and SPSS 21 for Windows programs.
Ethic
This study received approval from the Human Research Ethics Committee of Universidade Estadual Paulista (CAAE: 68062123.8.0000.5411).
RESULTS
The clinical characteristics of the 55 patients who underwent TxC from May 2019 to April 2023 are illustrated in Table 1. Of the 55 patients admitted to transplantation, 36 (65.45%) survived the surgery, 26 were male and 10 were female. The average age of the patients was 47 years, with an average body mass index (BMI) of 23 kg/m22 Brasil. Ministério da Saúde. DATASUS. Mortalidade. Brasília, 2016 [acesso em 12 Jul 2023]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/cnv/obt10uf.def
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. The average cardiopulmonary bypass (CPB) time was 255 minutes, and 51% of patients preoperatively used an intra-aortic balloon pump (IABP). Only 5% of patients required mechanical ventilation (MV) and ventricular assistance (VA) before transplantation.
Descriptive analysis of quantitative and qualitative variables of patients who underwent TxC from May 2019 to April 2023 (n = 55).
Regarding the causes of death in this population (Table 2), the main one was vasoplegic shock, followed by graft rejection and acute right ventricular (RV) failure. Other less frequent causes were cardiogenic shock, biventricular systolic dysfunction, blood dyscrasia and septic shock.
Descriptive analysis of the causes of death of 19 patients who underwent TxCfrom May 2019 to April 2023.
Comparisons were made between the clinical and laboratory variables of patients discharged after TxC and those who died. The results showed a statistically significant difference between the groups concerning creatinine in POI (p = 0.0002), pulmonary vascular resistance (PVR) (p = 0.0011), as well as PSAP (p < 0.0001) and the degree of pre-surgical functional capacity measured by BI (p = 0.0001) (Table 3).
Comparison of clinical and laboratory variables of patients discharged or died during hospitalization.
A logistic regression model was developed to analyze the outcome of death during hospitalization, considering the other predictor variables. Initially, a stepwise regression model was fitted and influential variables were gradually added to identify associated risk factors.
The increase in creatinine in the first 24 postoperative hours was identified as a significant risk factor for mortality during hospitalization (p = 0.0067). Likewise, RVP (p = 0.0185) and pulmonary artery systolic pressure (PASP) (p = 0.0415) showed a significant association (Table 4).
Model using the maximum likelihood estimation method with stepwise logistic regression, taking into account influencing variables to determine the risk factors associated with the outcome of deathduring the hospitalization of patients after TxC.
When constructing the ROC curve with the delta increase in creatinine in the first postoperative period compared to the baseline value, the cutoff point of 0.35 mg/dL was identified (Fig. 1). At this point, sensitivity is 0.76 and specificity is 0.90 (area under the curve: 0.908).
ROC curve considering creatinine delta of patients who underwent TxC from May 2019 to April 2023.
When analyzing the ROC curve for PSAP, we found a cutoff point 40.5 (Fig. 2). At this point, sensitivity is 0.89, and specificity is 0.86 (area under the curve: 0.940).
ROC curve considering the PSAP value of patients who underwent TxC from May 2019 to April 2023.
For PVR, the ROC curve’s analysis revealed a cutoff point of 2.23 Woods units (WU) (Fig. 3). At this point, sensitivity is 0.79, and specificity is 0.72 (area under the curve: 0.783).
ROC curve considering the PVR (WU) value of patients who underwent TxC from May 2019 to April 2023.
Table 5 shows the descriptive analysis of survivors, considering the phase I CR Variables. Of the 36 patients who underwent CR, the average number of days of hospitalization after surgery was 27. On average, they started CR on the 5th day after surgery. -operative and performed their first sitting and ambulation on the 6th and 13th days, respectively.
Descriptive analysis of quantitative variables of 36 patients who underwent CR afterTxC from May 2019 to April 2023.
Analysis was conducted using Pearson’s correlations between length of stay after TxC and physiotherapy variables and functionality with the 36 survivors after surgery. There was a positive correlation between the start of physiotherapy and the duration of hospitalization after TxC; that is, there was a significant association between the late start of physiotherapy and the patient’s more extended period of hospitalization, with a statistically significant difference (p = 0.013 ).
Furthermore, a negative correlation was identified between the patient’s functionality and length of stay, indicating that the lower the patient’s functional capacity, the longer the length of stay, and this relationship was also statistically significant (p = 0.007) (Table 6).
Pearson correlation analysis between length of stay after TxC, functional capacity and physiotherapy variables of the 36 patients who underwent TxC and RC from May 2019 to April 2023.
DISCUSSION
An increase in creatinine to a value greater than or equal to 0.35 mg/dL in the first 24 hours, PSAP with values greater than 40.5 mmHg and PVR to a value above 2.23 WU are associated with increased hospital mortality rates after TxC.
Acute kidney injury (AKI) is characterized by abrupt loss of kidney function. According to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, stage I is characterized by an increase in serum creatinine more significant than or equal to 0.3 mg/dL in 48 hours, an increase in serum creatinine ≥ 1.5-fold the baseline value in the last 7 days and urinary volume < 0.5 mL/kg/h for 6 hours1414 Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract 2012;120(4):c179-84. https://doi.org/10.1159/000339789
https://doi.org/10.1159/000339789...
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AKI is a frequent complication after TxC and is linked to a higher risk of early mortality1515 Jiang YY, Kong XR, Xue FL, Chen HL, Zhou W, Chai JW, et al. Incidence, risk factors and clinical outcomes of acute kidney injury after heart transplantation: a retrospective single center study. J Cardiothorac Surg 2020;15(1):302. https://doi.org/10.1186/s13019-020-01351-4
https://doi.org/10.1186/s13019-020-01351...
. García-Gigorro et al.1616 García-Gigorro R, Renes-Carreño E, Corres Peiretti MA, Arribas López P, Perez Vela JL, Gutierrez Rodríguez J, et al. Incidence, risk factors and outcomes of early acute kidney injury after heart transplantation: an 18-year experience. Transplantation 2018;102(11):1901-8. https://doi.org/10.1097/TP.0000000000002293
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found that patients with AKI, especially those requiring renal replacement therapy (RRT), had higher in-hospital mortality than those without AKI. However, after hospital discharge, AKI was not associated with poor long-term outcomes1616 García-Gigorro R, Renes-Carreño E, Corres Peiretti MA, Arribas López P, Perez Vela JL, Gutierrez Rodríguez J, et al. Incidence, risk factors and outcomes of early acute kidney injury after heart transplantation: an 18-year experience. Transplantation 2018;102(11):1901-8. https://doi.org/10.1097/TP.0000000000002293
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According to the results of this study, the increase in creatinine in the first 24 hours was shown to be a risk factor for mortality. In this context, the importance of implementing strategies to prevent or limit progression to AKI is emphasized, which, consequently, can improve the survival of these patients.
Pulmonary hypertension (PH) is known to be a poor prognostic factor after TxC1717 Kanwar M, Raina A, Aponte MP, Benza R. Pulmonary hypertension in potential heart transplant recipients: current treatment strategies. Curr Opin Organ Transplant 2015;20(5):570-6. https://doi.org/10.1097/MOT.0000000000000228
https://doi.org/10.1097/MOT.000000000000...
. In patients who are candidates for TxC, PSAP, PVR and other hemodynamic parameters are obtained by right heart catheterization. This invasive exam is considered the gold standard for diagnosing and classifying PH and is recommended for evaluating candidates for TxC1818 Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF; ESC/ERS Scientific Document Group. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Developed by the task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS). Endorsed by the International Society for Heart and Lung Transplantation (ISHLT) and the European Reference Network on rare respiratory diseases (ERN-LUNG). Eur Heart J 2022;43(38):3618-3731. https://doi.org/10.1093/eurheartj/ehac237
https://doi.org/10.1093/eurheartj/ehac23...
. Furthermore, PH is monitored non-invasively using indirect transthoracic echocardiogram measurements.
PVR must be calculated individually for each patient using the formula PVR = (mean pulmonary arterial pressure – pulmonary capillary occlusion pressure)/cardiac output. According to the 2022 European Society of Cardiology (ESC) Guideline, typical PVR values are between 0.3 and 2.0 WU1818 Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF; ESC/ERS Scientific Document Group. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Developed by the task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS). Endorsed by the International Society for Heart and Lung Transplantation (ISHLT) and the European Reference Network on rare respiratory diseases (ERN-LUNG). Eur Heart J 2022;43(38):3618-3731. https://doi.org/10.1093/eurheartj/ehac237
https://doi.org/10.1093/eurheartj/ehac23...
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Matkovic et al.1919 Matkovic M, Milicevic V, Bilbija I, Aleksic N, Cubrilo M, Nestorovic E, et al. Pulmonary artery hypertension as a risk factor for long-term survival after heart transplantation. Heart Surg Forum 2021;24(3):E544-E549. https://doi.org/10.1532/hsf.3789. PMID: 34173749
https://doi.org/10.1532/hsf.3789https://...
conducted an observational study with 44 patients to investigate the impact of preoperative PH on survival after HTx. They concluded that PH is a risk factor associated with a higher mortality rate within 30 days after HTx.
Another study2020 Cantero-Pérez EM, Sayago I, Sobrino-Márquez JM, Rangel-Sousa D, Grande-Trillo A, Rezaei K, et al. Impact of preoperative pulmonary hypertension on survival in patients undergoing elective heart transplant. Transplant Proc 2020;52(2):580-3. https://doi.org/10.1016/j.transproceed.2019.11.034
https://doi.org/10.1016/j.transproceed.2...
involving 102 patients after TxC investigated the relationship between the presence of PH and survival. Patients were divided into two groups: without PH (< 25 mmHg) and with PH (> 25 mmHg). Furthermore, the PH group was subdivided into mild (25 to 34 mmHg), moderate (35 to 44 mmHg) and severe (> 44 mmHg). Of the 102 patients evaluated, 61 (59.8%) had PH before TxC, with 25 classified as mild, 34 as moderate and two as severe. It is concluded that the presence of preoperative PH did not have a significant impact on survival after HTx. However, it is essential to highlight that only two patients were classified in the severe PH group, which may explain the lack of differences between the groups2020 Cantero-Pérez EM, Sayago I, Sobrino-Márquez JM, Rangel-Sousa D, Grande-Trillo A, Rezaei K, et al. Impact of preoperative pulmonary hypertension on survival in patients undergoing elective heart transplant. Transplant Proc 2020;52(2):580-3. https://doi.org/10.1016/j.transproceed.2019.11.034
https://doi.org/10.1016/j.transproceed.2...
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Comparing our sample with the study by Cantero et al.2020 Cantero-Pérez EM, Sayago I, Sobrino-Márquez JM, Rangel-Sousa D, Grande-Trillo A, Rezaei K, et al. Impact of preoperative pulmonary hypertension on survival in patients undergoing elective heart transplant. Transplant Proc 2020;52(2):580-3. https://doi.org/10.1016/j.transproceed.2019.11.034
https://doi.org/10.1016/j.transproceed.2...
, we observed significantly higher levels of PH. The mean PSAP of survivors was 33.3 mmHg, while in the death group, it was 51.5 mmHg. This discrepancy justifies our sample’s lower survival rate (65.45%) compared to the 79.9% survival reported by Cantero et al.2020 Cantero-Pérez EM, Sayago I, Sobrino-Márquez JM, Rangel-Sousa D, Grande-Trillo A, Rezaei K, et al. Impact of preoperative pulmonary hypertension on survival in patients undergoing elective heart transplant. Transplant Proc 2020;52(2):580-3. https://doi.org/10.1016/j.transproceed.2019.11.034
https://doi.org/10.1016/j.transproceed.2...
.
It was found that there was a significant association between the implementation of CR phase I and the length of hospital stay after TxC. Specifically, the earlier the patient started CR, the shorter the length of stay observed in this sample. These data are essential, as they show the dynamics between the early implementation of phase I CR and a reduced period of hospitalization after TxC.
This suggests that rehabilitation can play a fundamental role in post-surgical recovery, allowing patients to recover more quickly, avoiding complications related to prolonged hospitalization and facilitating the transition to hospital discharge. These results highlight the importance of including rehabilitation as an integral part of post-TxC care. In this context, conducting randomized clinical trials and more studies on phase 1 CR become essential, aiming to deepen our understanding of the specific benefits of this intervention in improving the prognosis and quality of life of patients undergoing heart transplants.
Rosenbaum et al.2121 Rosenbaum AN, Kremers WK, Schirger JA, Thomas RJ, Squires RW, Allison TG, et al. Association between early cardiac rehabilitation and long-term survival in cardiac transplant recipients. Mayo Clin Proc 2016;91(2):149-56. https://doi.org/10.1016/j.mayocp.2015.12.002
https://doi.org/10.1016/j.mayocp.2015.12...
conducted a retrospective study in which 201 patients who underwent CR after TxC were analyzed. Early CR was found to be associated with long-term survival after HTx.
Another relevant finding in this study was the negative correlation between the patient’s functionality, measured through the BI, and the length of stay. This observation means that the lower the patient’s functional capacity, the longer the hospitalization period. Although we cannot infer a cause-and-effect relationship due to the methodology used, the results highlight the importance of functionality in the duration of post-TxC hospitalization. This association highlights the need to consider patients’ functional capacity as a crucial aspect of postoperative management, although more research is needed to understand this relationship fully.
CR is beneficial in patients with HF, especially those awaiting transplantation, and is recommended as a class 1 indication (level of evidence A) in HF practice guidelines2222 Yancy CW, Jessup M, Bozkurt B, Butler J, Casey Júnior DE, Drazber MH. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;62(16):e147-239. https://doi.org/10.1016/j.jacc.2013.05.019
https://doi.org/10.1016/j.jacc.2013.05.0...
. Several systematic reviews indicate that patients with HF who undergo CR experience a reduction in mortality and hospitalization rates, in addition to an improvement in quality of life2323 Bozkurt B, Fonarow GC, Goldberg LR, Guglin M, Josephson RA; ACC’s Heart Failure and Transplant Section and Leadership Council. Cardiac rehabilitation for patients with heart failure: JACC Expert Panel. J Am Coll Cardiol 2021;77(11):1454-69. https://doi.org/10.1016/j.jacc.2021.01.030
https://doi.org/10.1016/j.jacc.2021.01.0...
,2424 Taylor RS, Walker S, Ciani O, Warren F, Smart NA, Piepoli M, et al. Exercise-based cardiac rehabilitation for chronic heart failure: the EXTRAMATCH II individual participant data meta-analysis. Health Technol Assess 2019;23(25):1-98. https://doi.org/10.3310/hta23250
https://doi.org/10.3310/hta23250...
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Unfortunately, despite the clear benefits in the literature, CR in the pre-TxC period remains underused2525 Grace SL, Gravely-Witte S, Brual J, Monette G, Suskin N, Higginson L, et al. Contribution of patient and physician factors to cardiac rehabilitation enrollment: a prospective multilevel study. Eur J Cardiovasc Prev Rehabil 2008;15(5):548-56. https://doi.org/10.1097/HJR.0b013e328305df05
https://doi.org/10.1097/HJR.0b013e328305...
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These findings emphasize the need to institute measures to preserve the patient’s functional capacity during hospitalization or outpatient care while waiting on the transplant waiting list through pre-TxC rehabilitation. Furthermore, it is vital to emphasize phase I CR for better outcomes after surgery.
The inherent limitation is that this is a single-center retrospective study with limited patients. As the implementation of TxC in this service is in its initial phase, we must consider some essential points: the impact of the team’s experience, the lack of availability of resources and infrastructure inherent to new services and the lack of longitudinal data on patients, which can limit analyzes and correlations with late complications.
CONCLUSION
An increase in creatinine to a value greater than or equal to 0.35 mg/dL in the first 24 hours, PSAP with values greater than 40.5 mmHg and PVR to a value above 2.23 WU are associated with increased hospital mortality rates after TxC.
ACKNOWLEDGEMENT
To Programa de Residência Multiprofissional em Saúde do Adulto e do Idoso and to Programa de Pós-Graduação em Fisiopatologia em Clínica Médica da Faculdade de Medicina de Botucatu.
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FUNDING
Not applicable.
DATA AVAILABILITY STATEMENT
All dataset were generated or analyzed in the current study.
REFERÊNCIAS
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1Almeida DE, Pereira-Barreto AC, Forestiero FJ, Nakamuta JS, Bichels A. A carga médica da insuficiência cardíaca: um delineamento comparativo com o câncer no Brasil. Int J Cardiovasc Sci 2022;35(4):514-20. https://doi.org/10.36660/ijcs.20200382
» https://doi.org/10.36660/ijcs.20200382 -
2Brasil. Ministério da Saúde. DATASUS. Mortalidade. Brasília, 2016 [acesso em 12 Jul 2023]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/cnv/obt10uf.def
» http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/cnv/obt10uf.def -
3Carvalho T, Milani M, Ferraz AS, Silveira ADD, Herdy AH, Hossri CAC, et al. Brazilian Cardiovascular Rehabilitation Guideline – 2020. Arq Bras Cardiol 2020;114(5):943-87. Erratum in: Arq Bras Cardiol 2021;117(2):423. https://doi.org/10.36660/abc.20200407
» https://doi.org/10.36660/abc.20200407 -
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Publication Dates
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Publication in this collection
12 Aug 2024 -
Date of issue
2024
History
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Received
23 Mar 2024 -
Accepted
16 June 2024