Primary graft dysfunction prevention strategies in the perioperative period

Primary graft dysfunction (PGD) remains a leading cause of early morbidity and mortality after heart and lung transplantation. It results from a multifactorial process involving ischemia-reperfusion injury, inflammatory and immune responses, and donor-, recipient-, and procedural factors. Despite advances in perioperative management, PGD continues to adversely affect both short- and long-term transplant outcomes.

This narrative review synthesizes contemporary evidence and consensus recommendations from the International Society for Heart and Lung Transplantation (ISHLT) and recent clinical studies to delineate perioperative strategies aimed at preventing PGD in heart and lung transplantation. Focus areas include donor and recipient optimization, organ preservation strategies, intraoperative management, and emerging perfusion technologies.

In heart transplantation, modifiable factors such as pre-transplant amiodarone exposure and donor-recipient mismatch increase PGD risk. Among preservation methods, hypothermic oxygenated perfusion has demonstrated reductions in PGD incidence, while controlled hypothermia has been associated with reduced PGD rates in observational studies. Normothermic ex vivo perfusion has shown improved graft preservation. In lung transplantation, the use of low-potassium dextran preservation solutions is associated with lower PGD rates. Ex vivo lung perfusion improves allograft utilization and may reduce PGD incidence. Implantation techniques such as off-pump lung transplantation or veno-arterial extracorporeal membrane oxygenation, rather than cardiopulmonary bypass, have been associated with lower PGD rates.

Every step of the transplant process is important in reducing the risk of PGD. Emerging machine perfusion technologies represent a promising advancement to enhance graft utilization, reduce PGD incidence, and improve overall outcomes following heart and lung transplantation.