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, Maryam; Apostolo, Anna; Salvioni, Elisabetta; Galotta, Arianna; Emdin, Michele; Piepoli, Massimo; Palazzuoli, Alberto; Sinagra, Gianfranco; Magrì, Damiano; Paolillo, Stefania; Mapelli, Massimo; Campodonico, Jeness; Corrà, Ugo; Raimondo, Rosa; Cittadini, Antonio; Iorio, Annamaria; Salzano, Andrea; Badagliacca, Roberto; Senni, Michele; Perrone-Filardi, Pasquale; Correale, Michele; Perna, Enrico; Metra, Marco; Vignati, Carlo; Contini, Mauro C; Baracchini, Nikita; Cattadori, Gaia; Guazzi, Marco; Limongelli, Giuseppe; Parati, Gianfranco; Pezzuto, Beatrice; Willixhofer, Robin; Palermo, Pietro; Matassini, Maria Vittoria; Bandera, Francesco; Bussotti, Maurizio; Carulli, Ermes; Re, Federica; Scardovi, Angela Beatrice; Sciomer, Susanna; Passantino, Andrea; Girola, Davide; Passino, Claudio; Adamo, Luigi; Agostoni, Piergiuseppe. - 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
Badagliacca, Roberto;Sciomer, Susanna;
2026
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.
