Background Current guidelines recommend evaluating patients with ambulatory heart failure (HF) for heart transplantation if their peak oxygen consumption (peak VO 2) is <12 mL/kg/min. However, these recommendations are based on decades-old data. Methods We retrospectively analysed 8060 patients with ambulatory HF with cardiopulmonary exercise testing (CPET) data. The primary analysis focused on 1218 patients with left ventricular ejection fraction <40% and peak VO 2 <12 mL/kg/min, enrolled between 2010 and 2022. Survival outcomes (composite of death/left ventricular assist device/heart transplantation) were compared with those of heart transplantation recipients from the International Society for Heart and Lung Transplantation registry. Patients were stratified by ventilatory efficiency (ventilation versus CO 2 production slope (VE/VCO 2) >34 vs ≤34) and presence of exercise oscillatory ventilation. Survival analyses were performed using Kaplan-Meier curves compared with log-rank tests and Cox proportional hazards models, with heart transplantation survival curves reconstructed from aggregate data. Results Patients with peak VO 2 <12 mL/kg/min demonstrated better survival than heart transplantation recipients, with survival curves intersecting at approximately 2.7 years. Among those with VE/VCO 2 ≤34, 10-year mortality risk was halved (p<0.01), with survival curves crossing those of heart transplantation recipients around year 4. Absence of exercise oscillatory ventilation was similarly associated with a 50% lower long-term mortality. Combining VE/VCO 2 and exercise oscillatory ventilation identified four distinct risk groups with significantly different 10-year outcomes (p<0.01). Patients with peak VO 2 <12 mL/kg/min, VE/VCO 2 ≤34 and no exercise oscillatory ventilation exhibited survival comparable to heart transplantation recipients at year 5. Conclusions In contemporary practice, a peak VO 2 <12 mL/kg/min alone may not reliably identify patients with HF with sufficiently high short-term mortality to warrant heart transplantation referral. VE/VCO 2 and exercise oscillatory ventilation provide important additional risk stratification, supporting re-evaluation of transplant referral criteria to reflect improved HF management and outcomes.
Cardiopulmonary exercise test criteria for heart transplantation referral of patients with ambulatory heart failure in the current era / Azar, M.; Apostolo, A.; Salvioni, E.; Galotta, A.; Emdin, M.; Piepoli, M.; Palazzuoli, A.; Sinagra, G.; Magri, D.; Paolillo, S.; Mapelli, M.; Campodonico, J.; Corra, U.; Raimondo, R.; Cittadini, A.; Iorio, A.; Salzano, A.; Badagliacca, R.; Senni, M.; Perrone-Filardi, P.; Correale, M.; Perna, E.; Metra, M.; Vignati, C.; Contini, M. C.; Baracchini, N.; Cattadori, G.; Guazzi, M.; Limongelli, G.; Parati, G.; Pezzuto, B.; Willixhofer, R.; Palermo, P.; Matassini, M. V.; Bandera, F.; Bussotti, M.; Carulli, E.; Re, F.; Scardovi, A. B.; Sciomer, S.; Passantino, A.; Girola, D.; Passino, C.; Adamo, L.; Agostoni, P.. - In: HEART. - ISSN 1355-6037. - (2026). [10.1136/heartjnl-2025-327208]
Cardiopulmonary exercise test criteria for heart transplantation referral of patients with ambulatory heart failure in the current era
Metra M.;
2026-01-01
Abstract
Background Current guidelines recommend evaluating patients with ambulatory heart failure (HF) for heart transplantation if their peak oxygen consumption (peak VO 2) is <12 mL/kg/min. However, these recommendations are based on decades-old data. Methods We retrospectively analysed 8060 patients with ambulatory HF with cardiopulmonary exercise testing (CPET) data. The primary analysis focused on 1218 patients with left ventricular ejection fraction <40% and peak VO 2 <12 mL/kg/min, enrolled between 2010 and 2022. Survival outcomes (composite of death/left ventricular assist device/heart transplantation) were compared with those of heart transplantation recipients from the International Society for Heart and Lung Transplantation registry. Patients were stratified by ventilatory efficiency (ventilation versus CO 2 production slope (VE/VCO 2) >34 vs ≤34) and presence of exercise oscillatory ventilation. Survival analyses were performed using Kaplan-Meier curves compared with log-rank tests and Cox proportional hazards models, with heart transplantation survival curves reconstructed from aggregate data. Results Patients with peak VO 2 <12 mL/kg/min demonstrated better survival than heart transplantation recipients, with survival curves intersecting at approximately 2.7 years. Among those with VE/VCO 2 ≤34, 10-year mortality risk was halved (p<0.01), with survival curves crossing those of heart transplantation recipients around year 4. Absence of exercise oscillatory ventilation was similarly associated with a 50% lower long-term mortality. Combining VE/VCO 2 and exercise oscillatory ventilation identified four distinct risk groups with significantly different 10-year outcomes (p<0.01). Patients with peak VO 2 <12 mL/kg/min, VE/VCO 2 ≤34 and no exercise oscillatory ventilation exhibited survival comparable to heart transplantation recipients at year 5. Conclusions In contemporary practice, a peak VO 2 <12 mL/kg/min alone may not reliably identify patients with HF with sufficiently high short-term mortality to warrant heart transplantation referral. VE/VCO 2 and exercise oscillatory ventilation provide important additional risk stratification, supporting re-evaluation of transplant referral criteria to reflect improved HF management and outcomes.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
