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Prognostic implications of the updated ISHLT definition for severe graft dysfunction: An analysis from the
N K Dhingra1, A D Devore2, S A Hall3
1University Health Network, Toronto, ON, Canada.
Insights
The 2024 ISHLT definition for severe graft dysfunction after heart transplant (HT) may obscure prognosis by including de novo intra-aortic balloon pump (IABP) use. Patients with IABP support show better survival than those with severe PGD.
Area of Science:
- Cardiology
- Transplant Surgery
- Immunology
Background:
- The 2014 International Society for Heart and Lung Transplantation (ISHLT) criteria define severe primary graft dysfunction (PGD) post-heart transplant (HT).
- The proposed 2024 ISHLT definition includes de novo intra-aortic balloon pump (IABP) support as indicative of severe PGD.
Purpose of the Study:
- To evaluate the prognostic implications of reclassifying patients based on the new 2024 ISHLT severe early graft dysfunction (EGD) criteria.
- To compare survival outcomes between patients meeting 2014 severe PGD criteria, those reclassified due to de novo IABP use, and those not meeting severe PGD criteria.
Main Methods:
- Analysis of 7,239 heart transplant recipients from the International Consortium on PGD and United Network for Organ Sharing (UNOS) registries.
- Categorization into three groups: 2014 severe PGD, reclassified as severe EGD by 2024 criteria (de novo IABP within 24 hours), and no severe PGD.
- Comparison of unadjusted survival using Kaplan-Meier curves and log-rank tests; multivariable Cox regression for 1-year mortality risk.
Main Results:
- Patients with de novo IABP (Group 2) had significantly lower 1-year mortality (9.6-12.1%) compared to those with 2014 severe PGD (27.2-36.3%).
- Survival for de novo IABP patients more closely resembled those without severe PGD (5.6-7.4%).
- Adjusted analysis showed reduced 1-year mortality risk for de novo IABP (HR 0.30) and no severe PGD (HR 0.17) groups compared to 2014 severe PGD.
Conclusions:
- Isolated de novo IABP use within 24 hours post-HT is associated with significantly better survival than severe PGD requiring ECMO or VAD support.
- The 2024 ISHLT definition may obscure prognostic differences by combining disparate patient groups.
- This reclassification may diminish the recognition of the most severe PGD phenotypes.
Purpose:
The proposed 2024 ISHLT consensus definition for severe graft dysfunction after heart transplant (HT) expands the 2014 criteria by including de novo intra-aortic balloon pump (IABP) support as diagnostic for severe dysfunction. We evaluated the prognostic implications of this reclassification using data from the International Consortium on PGD (herein 'Consortium') and United Network for Organ Sharing (UNOS) registries.
Methods:
Heart Transplant (HT) recipients were categorized into the following groups (1) meeting 2014 severe PGD criteria, (2) reclassified as severe early graft dysfunction (EGD) by the 2024 criteria based on a newly placed IABP within 24 h of HT, or (3) not meeting severe PGD criteria. KM survival curves and log-rank tests were used to compare unadjusted survival. A multivariable Cox regression model was used to determine the association of group status on 1 year mortality.
Results:
A total of 7239 HT recipients with relevant data were included in this analysis: 4087 in the Consortium and 3152 from UNOS. In the Consortium cohort, 361 (8.8%), 116 (2.8%), and 3610 (88.3%) patients comprised Groups 1, 2 and 3, respectively. Group 1 had more pre-transplant temporary and durable mechanical circulatory support, along with longer ischemic times. At 1 year post-HT, mortality in patients with de novo IABP (12.1% in Consortium, 9.6% in UNOS) was significantly lower than in patients with 2014 severe PGD (36.3% in Consortium, 27.2% in UNOS), and more closely resembled those without severe PGD (7.4% in Consortium, 5.6% in UNOS) [Log-rank p < 0.001 in both groups]. After adjustment for potential confounders, both reclassified patients with a de novo IABP [Group 2: HR 0.30 (0.17-0.51)] and patients without severe PGD [Group 3: HR 0.17 (0.14-0.22)] had significantly reduced risk of 1 year mortality compared to those with 2014 severe PGD (P<0.001) in the Consortium. These findings were replicated in the UNOS population.
Conclusion:
In this analysis of two contemporary, multicentre databases, patients who received an isolated de novo IABP within the first 24 h postoperatively had significantly better survival than those who were dependent on extra-corporeal membrane oxygenation (ECMO) or ventricular assist devices after HT. Combining these disparate patient groups in the new severe PGD definition may obscure prognostic differences and diminish recognition of the most severe PGD phenotype.
