The Preoperative Role of Right-Sided Heart Function in Primary Graft Dysfunction After Bilateral Lung Transplantation

There are conflicting reports on the role of hyperdynamic right ventricular (RV) function contributing to ischemia-reperfusion injury and the development of primary graft dysfunction (PGD) after lung transplantation (LTx). We evaluated preoperative right atrial (RA) and RV strain in LTx patients and tested their predictive role in development of PGD and overall survival.

Preoperative echocardiography of patients who underwent bilateral LTx at a single center from 2014 to 2025 was analyzed for RA strain as well as for RV free wall and global longitudinal strain. The presence of PGD grade 3 was defined as a partial pressure of arterial oxygen/fractional inspired oxygen ratio <200 mm Hg at 48 or 72 hours after the operation.

Overall, we analyzed 157 patients; PGD developed in 46 (29.3%). Patients with PGD demonstrated worse preoperative RV function, shown by decreased RV free wall strain (-19.5% ± 6.5% vs -15.2% ± 7.3%; P < .001) and RV global longitudinal strain (-16.5% ± 4.8% vs -12.3% ± 5.2%; P < .001). Patients with PGD had decreased preoperative cardiac index (P = .014), increased pulmonary vascular resistance (P = .020), and increased mean pulmonary arterial pressure (P = .038). None of the RV or RA strain variables were predictive of all-cause mortality. The presence of PGD was significantly associated with increased mortality, with 2-year mortality of 20.1% and 48.0% for patients without and with PGD, respectively.

Our study suggests that preoperatively reduced RV and RA function along with decreased cardiac index is associated with the development of PGD. The reduced right-sided heart function was not predictive of long-term survival.