Utility of Recipient Cardiothoracic Ratio in Predicting Delayed Chest Closure after Heart Transplantation

Abstract

Background Predicted cardiac mass (PCM) has been well validated for size matching donor hearts to heart transplantation recipients. We hypothesized that cardiothoracic ratio (CTR) could be reflective of recipient-specific limits of oversizing, and sought to determine the utility of donor to recipient PCM ratio (PCMR) and CTR in predicting delayed chest closure after heart transplantation.

Methods A retrospective review of prospectively collected data on 38 consecutive heart transplantations performed at our institution from 2017 to 2020 was performed. Donor and recipient PCM were estimated using Multi-Ethnic Study of Atherosclerosis predictive models. Receiver operating characteristic analysis was performed to determine the discriminatory power of the ratio of PCMR to CTR in predicting delayed sternal closure.

Results Of the 38 patients, 71.1% (27/38) were male and the median age at transplantation was 58 (interquartile range [IQR]: 47–62) years. Ischemic cardiomyopathy was present in 31.6% of recipients (12/38). Median recipient CTR was 0.63 [IQR: 0.59–0.66]. Median donor to recipient PCMR was 1.07 [IQR: 0.96–1.19], which indicated 7% oversizing. Thirteen out of 38 (34.2%) underwent delayed sternal closure. Primary graft dysfunction occurred in 15.8% (6/38). PCMR/CTR showed good discriminatory power in predicting delayed sternal closure [area under the curve: 80.4% (65.3–95.6%)]. PCMR/CTR cut-off of 1.7 offered the best trade-off between the sensitivity (69.6%) and specificity (91.7%).

Conclusion CTR could be helpful in guiding the recipient-specific extent of oversizing donor hearts. Maintaining the ratio of PCMR to CTR below 1.7 could avoid excessive oversizing of the donor heart.

Keywords

heart transplantation - cardiothoracic ratio - delayed sternal closure - DSC - HTx - predicted cardiac mass

Note

The abstract on which this manuscript is based was presented at ISHLT; Toronto, Canada; April 27 to 30, 2021. It was published in the Journal of Heart and Lung transplantation.

Publication History

Received: 25 July 2022

Accepted: 12 January 2023

Accepted Manuscript online:
18 January 2023

Article published online:
09 March 2023

• References

• 1 O'Neill IV TJ, Pisani B. Size matching in heart transplantation donor selection: “Too big to fail”?. J Heart Lung Transplant 2017; 36 (09) 934-935
• 2 Fung K, Cheshire C, Cooper JA. et al. Validation of cardiovascular magnetic resonance-derived equation for predicted left ventricular mass using the UK Biobank imaging cohort: tool for donor-recipient size matching. Circ Heart Fail 2019; 12 (12) e006362
• 3 Kobashigawa J, Khush K, Colvin M. et al. Report from the American Society of Transplantation Conference on donor heart selection in adult cardiac transplantation in the United States. Am J Transplant 2017; 17 (10) 2559-2566
• 4 Bergenfeldt H, Stehlik J, Höglund P, Andersson B, Nilsson J. Donor-recipient size matching and mortality in heart transplantation: influence of body mass index and gender. J Heart Lung Transplant 2017; 36 (09) 940-947
• 5 Holzhauser L, Imamura T, Bassi N. et al. Increasing heart transplant donor pool by liberalization of size matching. J Heart Lung Transplant 2019; 38 (11) 1197-1205
• 6 Eberlein M, Reed RM. Donor to recipient sizing in thoracic organ transplantation. World J Transplant 2016; 6 (01) 155-164
• 7 Reed RM, Netzer G, Hunsicker L. et al. Cardiac size and sex-matching in heart transplantation : size matters in matters of sex and the heart. JACC Heart Fail 2014; 2 (01) 73-83
• 8 Bluemke DA, Kronmal RA, Lima JAC. et al. The relationship of left ventricular mass and geometry to incident cardiovascular events: the MESA (Multi-Ethnic Study of Atherosclerosis) study. J Am Coll Cardiol 2008; 52 (25) 2148-2155
• 9 Kawut SM, Lima JAC, Barr RG. et al. Sex and race differences in right ventricular structure and function: the multi-ethnic study of atherosclerosis-right ventricle study. Circulation 2011; 123 (22) 2542-2551
• 10 Tremblay-Gravel M, Khush K. Predicted heart mass for donor organ allocation: getting closer to the target. Circ Heart Fail 2019; 12 (12) e006634
• 11 Kransdorf EP, Kittleson MM, Benck LR. et al. Predicted heart mass is the optimal metric for size match in heart transplantation. J Heart Lung Transplant 2019; 38 (02) 156-165
• 12 Cheshire C, Kydd A, Nerlekar N. et al. Size matching in heart transplantation: is predicted heart mass the optimal method in a United Kingdom cohort?. Clin Transplant 2021; 35 (03) e14192
• 13 Camarda J, Saudek D, Tweddell J. et al. MRI validated echocardiographic technique to measure total cardiac volume: a tool for donor-recipient size matching in pediatric heart transplantation. Pediatr Transplant 2013; 17 (03) 300-306
• 14 Christenson JT, Maurice J, Simonet F, Velebit V, Schmuziger M. Open chest and delayed sternal closure after cardiac surgery. Eur J Cardiothorac Surg 1996; 10 (05) 305-311
• 15 Li M, Mazzeffi MA, Gammie JS. et al. Characterization of postoperative infection risk in cardiac surgery patients with delayed sternal closure. J Cardiothorac Vasc Anesth 2020; 34 (05) 1238-1243
• 16 Berman M, Erez E, Ben-Gal T, Sahar G, Vidne B, Aravot D. Importance of the cardiothoracic ratio in the evaluation of cardiac transplant candidates. Transplant Proc 1999; 31 (04) 1885-1886
• 17 Truszkiewicz K, Poręba R, Gać P.. Radiological cardiothoracic ratio in evidence-based medicine. J Clin Med 2021; 10 (09) 2016
• 18 Sukhavasi A, Weber MP, Maynes EJ. et al. Utility of recipient cardiothoracic ratio in predicting delayed chest closure after heart transplantation. J Heart Lung Transplant 2021; 40 (04) S260-S261
• 19 Jiang L, Chen WG, Geng QS. et al. The cardiothoracic ratio: a neglected preoperative risk-stratified method for patients with rheumatic heart disease undergoing valve replacement surgery. Eur J Cardiothorac Surg 2019; 55 (03) 511-517
• 20 Giamouzis G, Sui X, Love TE, Butler J, Young JB, Ahmed A. A propensity-matched study of the association of cardiothoracic ratio with morbidity and mortality in chronic heart failure. Am J Cardiol 2008; 101 (03) 343-347
• 21 Zhu Y, Xu H, Zhu X. et al. Association between cardiothoracic ratio, left ventricular size and systolic function in patients undergoing computed tomography coronary angiography. Exp Ther Med 2014; 8 (06) 1757-1763
• 22 Grotenhuis HB, Zhou C, Tomlinson G. et al. Cardiothoracic ratio on chest radiograph in pediatric heart disease: how does it correlate with heart volumes at magnetic resonance imaging?. Pediatr Radiol 2015; 45 (11) 1616-1623
• 23 Yotsueda R, Taniguchi M, Tanaka S. et al. Cardiothoracic ratio and all-cause mortality and cardiovascular disease events in hemodialysis patients: the Q-Cohort study. Am J Kidney Dis 2017; 70 (01) 84-92
• 24 Hsu HJ, Wu IW, Hsu KH, Sun CY, Chen CY, Lee CC. Vitamin D deficiency, cardiothoracic ratio, and long-term mortality in hemodialysis patients. Sci Rep 2020; 10 (01) 7533
• 25 Ito K, Ookawara S, Ueda Y. et al. A higher cardiothoracic ratio is associated with 2-year mortality after hemodialysis initiation. Nephron Extra 2015; 5 (03) 100-110
• 26 Wanapirak C, Sirichotiyakul S, Luewan S, Srisupundit K, Tongprasert F, Tongsong T. Appearance of abnormal cardiothoracic ratio of fetuses with hemoglobin Bart's disease: life table analysis. Ultraschall Med 2017; 38 (05) 544-548
• 27 Miller RJH, Hedman K, Amsallem M. et al. Donor and recipient size matching in heart transplantation with predicted heart and lean body mass. Semin Thorac Cardiovasc Surg 2022; 34 (01) 158-167
• 28 Furnary AP, Magovern JA, Simpson KA, Magovern GJ. Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg 1992; 54 (02) 233-239
• 29 Takayama H, Leone RJ, Aldea GS, Fishbein DP, Verrier ED, Salerno CT. Open-chest management after heart transplantation. Tex Heart Inst J 2006; 33 (03) 306-309
• 30 Kobashigawa J, Zuckermann A, Macdonald P. et al; Consensus Conference participants. Report from a consensus conference on primary graft dysfunction after cardiac transplantation. J Heart Lung Transplant 2014; 33 (04) 327-340