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J Heart Lung Transplant. 2015 Mar;34(3):319-28. doi: 10.1016/j.healun.2014.11.012. Epub 2014 Nov 12.

Assessment of right ventricular adaptability to loading conditions can improve the timing of listing to transplantation in patients with pulmonary arterial hypertension.

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Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany. Electronic address:
Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany.



Right ventricle (RV) performance is load dependent, and right-sided heart failure (RHF) is the main cause of death in pulmonary arterial hypertension (PAH). Prediction of RV worsening for timely identification of patients needing transplantation (Tx) is paramount. Assessment of RV adaptability to load has proved useful in certain clinical circumstances. This study assessed its predictive value for RHF-free and Tx-free outcome with PAH.


Between 2006 and 2012, all potential Tx candidates with PAH, without RHF at the first evaluation, were selected for follow-up (except congenital heart diseases). At selection and at each follow-up, N-terminal prohormone brain natriuretic peptide (NT-proBNP) and the 6-minute walk distance were measured, and RV adaptability to load was assessed by echocardiography. Collected data were tested for the ability to predict RV stability and Tx-free survival.


During a 12-month to 92-month follow-up, RHF developed in 23 of 79 evaluated patients, despite similar medication and no differences in initial RV size and ejection fraction compared with the patients who remained stable. However, unstable patients had an initially lower RV load-adaptation index and afterload-corrected peak global systolic longitudinal strain-rate values as well as higher RV dyssynchrony, tricuspid regurgitation, and NT-proBNP levels (p ≤ 0.01). At certain cutoff values, these variables appeared predictive for 1-year and 3-year freedom from RHF and 3-year Tx-free survival. An RV load-adaptation index reduction of ≥20% showed the highest predictive value (90.0%) for short-term (≤1 year) RV decompensation.


Assessment of RV adaptability to load allows prediction of RV function and Tx-free survival with severe PAH during the next 1 to 3 years. This can improve the timing of listing for Tx.


echocardiography; heart failure; pulmonary hypertension; right ventricle; transplantation

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