PREDICTION OF IMPROVEMENT IN RECENT-ONSET CARDIOMYOPATHY AFTER REFERRAL FOR HEART-TRANSPLANTATION

Objectives. The purpose of this investigation was to determine how often left ventricular function improves in recent onset dilated cardiomyopathy of sufficient severity to cause referral for heart transplantation and how to predict this improvement at the time of evaluation for transplantation. Background. Improvement has been reported to occur frequently in patients with acute dilated cardiomyopathy but has not been described specifically in these patients referred for transplantation. To avoid potentially needless transplantation, it would be useful to know the frequency of improvement and how to predict it in these patients. Methods. A consecutive series of 297 patients with primary dilated cardiomyopathy evaluated for heart transplantation was reviewed to identify those with onset of heart failure symptoms within the preceding 6 months and to examine their outcome. The clinical, echocardiographic, hemodynamic and laboratory profiles of patients with improvement in left ventricular function (defined as an increase in left ventricular ejection fraction greater than or equal to 0.15 to a final ejection fraction of greater than or equal to 0.30) were compared with those of patients without improvement to assess which variables might predict improvement. Results. Of 49 patients with recent onset dilated cardiomyopathy, 13 (27%) showed improvement, with an increase in mean left ventricular ejection fraction from 0.22 +/- 0.08 to 0.49 +/- 0.09. All patients with improvement had survived without heart transplantation at 43 +/- 29 months. Survival time was shorter in the remaining 36 patients without improvement with recent onset cardiomyopathy than in the 248 with chronic symptoms (p = 0.03) and in younger compared with older patients with recent onset cardiomyopathy (p = 0.0001). By multivariate analysis, predictors of improvement were shorter duration of symptoms, lower pulmonary wedge and right atrial pressures and higher serum sodium levels. Conclusions. A minority of patients with dilated cardiomyopathy and symptoms for less than or equal to 6 months will have marked improvement in left ventricular function, after which prognosis is excellent despite previous referral for heart transplantation. Those with symptom duration >3 months and more severe initial decompensation as reflected by higher filling pressures and lower serum sodium levels are unlikely to show improvement and may require earlier consideration for heart transplantation.