Extracorporeal life support in primary transplant failure: what are the options?

Heart transplantation (HTx) is still the gold standard in terminal heart failure. Each year, more than 4000 adult heart transplantations are performed worldwide. Despite significant advances in perioperative management during the last 4 decades, the 30 day mortality is still at 5-10% due to early graft failure. Primary graft dysfunction (PGD) occurs within the first 24 h after heart transplantation and is manifested as right, left or biventricular dysfunction. The etiology is not limited to a single cause but instead depends on a multitude of donor-related and recipient-related risk factors. Furthermore, the transplantation process itself leads to an array of negative influences on the graft, such as catecholamine excess during brain death, cold and warm ischemia and reperfusion injury. Treatment of PGD is primarily supportive and necessitates further escalation according to clinical requirements. First-line treatment is inotropes or phosphodiesterase inhibitors. In isolated right ventricular (RV) PGD nitrous oxide can be used to lower pulmonary vascular resistance and RV afterload. Severe cases of PGD require the use of mechanical circulatory support (MCS) to achieve ventricular unloading. The indications should be set as early as possible, as this can improve the efficacy and outcome. In contrast to previous treatment strategies, the current goal of treatment has shifted from bridging to retransplantation to successful weaning from MCS, while preserving end organ function as much as possible.