Cardiogenic shock in heart transplant recipients: A multicenter cohort study with matched analysis

This study aimed to evaluate the prognosis of heart transplant recipients (HTR) with graft failure-related cardiogenic shock (CS), identify predictors of 1-year event-free survival, and compare their outcomes to those of patients with other CS etiologies.

This retrospective multicenter study included all HTR admitted to the ICU between June 2006 and August 2024 for CS occurring ≥ 1 month after transplantation. The primary endpoint was 1-year survival, without retransplantation or long-term circulatory support. HTR receiving VA-ECMO were compared with propensity score matching to 2 external ECMO control cohorts: (1) patients with CS due to acute myocardial infarction (AMICS); and (2) immunocompromised patients with CS from various causes.

Among the 145 HTR included, the primary causes of shock were cardiac allograft rejection (51%), coronary allograft vasculopathy (19%), and other causes (30%), with no significant differences in survival across etiologies. Event-free survival was 25% at one year. Independent predictors of 1-year event-free survival included CAV grade ≥2 (HR 2.4; 95% CI, 1.6-3.7), renal replacement therapy at ICU admission (HR 1.9; 95% CI, 1.2-3.1), SCAI stage of cardiogenic shock ≥ D (HR 3.6; 95% CI 2.1 to 6.3), and ECMO initiated on cardiopulmonary resuscitation (HR 2.5; 95% CI, 1.5-4.1). In a matched analysis of VA-ECMO patients, heart transplant recipients had significantly lower 90-day survival than matched AMICS patients (22% vs 55%), whereas survival was not significantly different when compared with other immunocompromised non-transplant patients (28% vs 42%).

CS occurring after heart transplantation is associated with very poor outcomes, with only one quarter of patients free from death, retransplantation, or durable mechanical circulatory support at 1 year. While prognosis appeared worse than in matched patients with AMICS requiring VA-ECMO, outcomes did not significantly differ from those of other immunocompromised patients receiving the same support.