Predictors and outcomes of severe primary graft dysfunction in heart transplantation: United States cohort analysis

This study aims to assess predictors and outcomes of severe primary graft dysfunction (PGD) in a contemporary United States cohort.

The United Network for Organ Sharing database was retrospectively reviewed for isolated adult heart transplant recipients (September 2023-March 2025). The population was stratified into severe PGD (left or biventricular dysfunction within 24 hours following transplantation that requires mechanical circulatory support [MCS]) and control cohorts (all other recipients). Predictors of severe PGD were identified using multivariable logistic regression. The severe PGD cohort was further classified into transient severe primary graft dysfunction (TPGD, MCS off by 72 hours) vs. persistent severe primary graft dysfunction (PPGD, remained on MCS at 72 hours). The Kaplan-Meier method was used to compare 3-month survival between groups.

During the study interval, 5,097 heart transplant recipients were identified in the United States, with 6.6% (n = 338) developing severe PGD. Predictors for severe PGD included pretransplant extracorporeal membrane oxygenation (adjusted odds ratio [AOR]: 2.55, p < 0.001), hearts from donation after circulatory death (AOR: 2.13, p < 0.001), donor acidemia before procurement (AOR: 2.01, p < 0.001), and recipient history of sternotomy (AOR: 1.83, p < 0.001). The severe PGD group experienced lower 3-month survival than the control group (74.4% vs 96.8%, p < 0.001). Among severe PGD cases, 36.7% (n = 124) experienced TPGD and had higher 3 month survial than PPGD group (88.0% vs 67.2%, p < 0.001).

Severe PGD following heart transplantation is associated with high early mortality. Consideration of risk factors in donor and recipient matching may mitigate the incidence of severe PGD.