Rv-to-pa Coupling Is A Strong Determinant Of Post-operative Course In Patients With Congenital Heart Disease Operated At Older Ages- A First-in-literature Ml -guided Predictive Model In Indian Patients For A Topic “Less Spoken About”

• Published in: Journal of cardiac failure Vol. 31; no. 1; p. 216
• Main Authors: Kini, Prayaag, Varyani, Reeta
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.01.2025
• ISSN: 1071-9164
• DOI: 10.1016/j.cardfail.2024.10.094

Older patients with congenital heart disease (CHD) with moderate to severe grades of pulmonary arterial hypertension (PAH) are considered to be at risk for pulmonary hypertensive crisis (PHC) or even mortality in immediate post-operative period, and become candidates for right heart failure (RHF).We still get significant number of patients who are operated at older ages for CHD. There is ample knowledge on pediatric patients on this subject but sparse in patients diagnosed late in life and thus operated at older ages. Our retrospective analysis with prospective validation was designed to identify the risks and clinical characteristics associated with PHC in CHD PAH patients operated at >12 years of age and older. We included 108 consecutive patients who underwent diagnostic RHC and were operated between from Jan 1,2016-Jan 1,2020 with near-complete follow-up. The mean patient age was 19.0 ± 3.7 years and 58.5% were males. Before surgery, around 69% of patients were in NYHA class II and 21 % in class III. Sedation with short-acting general i.v. anaesthesia was used in 90.2% during RHC, with spontaneous breathing or mild sedation alone in rest. Standard RHC and LHC was done in all patients for PVR, PVRi, shunt fraction and PVRi/SVRi. A dedicated echocardiographic study specifically measuring parameters for RV function and PAH such as TAPSE, TAPSE/ PASP/Tricuspid valve E’ by Tissue Doppler, RVSP by TR jet, PA mean systolic and diastolic pressures by PR jet, along with other usually measured indices was also performed. In the population that developed PHC, we analysed predictors for development of PHC by comparing with those who did not develop PHC by logistic regression using multivariate analysis and Precision- Recall curves. A model was created by giving weightage to predictors as per their hazard ratios and a predictive composite model score was generated for forward validation. The primary end point of PH crisis or need for reintubation/re-ventilation, or rehospitalisation occurred in 20 patients (18.4%), with frank PHC in 11 of these(10.2%) in the immediate post-op period or up to 1 year thereafter; there were three mortalities. Compared to patients without PHC, those who experienced PHC were more likely to be in NYHA class III (p = 0.021) before RHC. Multivariate logistic regression for PHC identified lower TAPSE/PASP ratio <0.3(p=0.011),lower fall in PAedp and PVRI in post-oxygen oximetry in the pre-surgical RHC, and TV E/E’ >11 (all p<0.05 for significance) as predictive of PHC. The classical Sitbon definition had actually lower AUROC values than the other parameters though it reached significance. A composite score of 14 was created and validated in a forward cohort of 56 patients with internal and external validation.