Cardiac Transplantation Primary Graft Dysfunction Incidence and Predictors

Purpose Primary graft dysfunction (PGD) is the leading cause of mortality within 30 days following heart transplantation (HT). We sought to identify the incidence and outcomes of PGD in our HT population. Methods We reviewed peri-operative clinical data of consecutive patients who underwent HT at our center (10/2012 - 12/2016). Using the 2014 ISHLT PGD definition and classification, PGD patients were identified and further classified into mild (MILD-PGD), moderate (MOD-PGD), and severe (SEV-PGD) left ventricular PGD. For each PGD patient, further data obtained included comorbidities, pre-transplant hemodynamics, donor information (comorbidities, hemodynamics cause of death), ischemic time, intra-operative bleeding and transfusion requirements, and peri-operative renal and hepatic function. RADIAL scores were calculated for all studied PGD patients. Results Of our 181 HT patients, 29 patients developed PGD (16%), of which 21% were MILD-PGD, 27% were MOD-PGD, and 52% were SEV-PGD. Before HT, 17/29 of patients were on amiodarone. Further, 7/15 of the SEV-PGD patients had mechanical circulatory support (MCS; 6 LVAD/ 1 TAH), and 4/8 of MOD-PGD patients had MCS (3 LVAD/ 1 TAH). The pre-operative right atrial pressures were higher in SEV-PGD patients when compared to MILD-PGD (p=0.003) and when compared to MOD-PGD (p=0.004). More SEV-PGD patients had a higher donor inotrope requirement (87%) than the MOD-PGD patients (38%; p=0.026) or the MILD-PGD patients (33%; p=0.031). They also had a higher intra-operative blood loss than the MILD-PGD group (p=0.0197). With respect to MOD-PGD, SEV-PGD had a higher pulmonary vascular resistance (p=0.0481). There was no difference in RADIAL scores between groups. Survival to hospital discharge was 79%. Three of the 29 PGD patients died within 30 days; and within one year, 7/29 patients died. Of the 7 deceased patients, 6 had SEV-PGD and 1 had MOD-PGD. In addition, SEV-PGD had earlier post-operative hemodynamic decline compared with MILD-PGD (p<0.0001). 11/15 patients with SEV-PGD required renal replacement therapy after transplantation vs 2 of MOD-PGD and none of MILD-PGD patients. Conclusion Among HT patients with PGD, pre-operative right atrial pressure, pulmonary vascular resistance, donor inotrope requirement, and intra-operative blood loss are predictive of the development of SEV-PGD. No differences in RADIAL scores were found. Primary graft dysfunction (PGD) is the leading cause of mortality within 30 days following heart transplantation (HT). We sought to identify the incidence and outcomes of PGD in our HT population. We reviewed peri-operative clinical data of consecutive patients who underwent HT at our center (10/2012 - 12/2016). Using the 2014 ISHLT PGD definition and classification, PGD patients were identified and further classified into mild (MILD-PGD), moderate (MOD-PGD), and severe (SEV-PGD) left ventricular PGD. For each PGD patient, further data obtained included comorbidities, pre-transplant hemodynamics, donor information (comorbidities, hemodynamics cause of death), ischemic time, intra-operative bleeding and transfusion requirements, and peri-operative renal and hepatic function. RADIAL scores were calculated for all studied PGD patients. Of our 181 HT patients, 29 patients developed PGD (16%), of which 21% were MILD-PGD, 27% were MOD-PGD, and 52% were SEV-PGD. Before HT, 17/29 of patients were on amiodarone. Further, 7/15 of the SEV-PGD patients had mechanical circulatory support (MCS; 6 LVAD/ 1 TAH), and 4/8 of MOD-PGD patients had MCS (3 LVAD/ 1 TAH). The pre-operative right atrial pressures were higher in SEV-PGD patients when compared to MILD-PGD (p=0.003) and when compared to MOD-PGD (p=0.004). More SEV-PGD patients had a higher donor inotrope requirement (87%) than the MOD-PGD patients (38%; p=0.026) or the MILD-PGD patients (33%; p=0.031). They also had a higher intra-operative blood loss than the MILD-PGD group (p=0.0197). With respect to MOD-PGD, SEV-PGD had a higher pulmonary vascular resistance (p=0.0481). There was no difference in RADIAL scores between groups. Survival to hospital discharge was 79%. Three of the 29 PGD patients died within 30 days; and within one year, 7/29 patients died. Of the 7 deceased patients, 6 had SEV-PGD and 1 had MOD-PGD. In addition, SEV-PGD had earlier post-operative hemodynamic decline compared with MILD-PGD (p<0.0001). 11/15 patients with SEV-PGD required renal replacement therapy after transplantation vs 2 of MOD-PGD and none of MILD-PGD patients. Among HT patients with PGD, pre-operative right atrial pressure, pulmonary vascular resistance, donor inotrope requirement, and intra-operative blood loss are predictive of the development of SEV-PGD. No differences in RADIAL scores were found.