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Updated: Oct 24, 2026
Cardiac Loading using Passive Left Atrial Pressurization and Passive Afterload for Graft Assessment
Published on: August 2, 2024
National Evaluation of the Updated ISHLT Early Graft Dysfunction Framework in Adult Heart Transplantation: Diagnostic
Marc Leon1, Chawannuch Ruaengsri, Hao He
1Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA.
Background:
The International Society for Heart and Lung Transplantation recently published a revised consensus on graft dysfunction after heart transplantation, introducing substantial modifications, including a shift toward more stringent conjunctive physiologic criteria. How these changes affect disease incidence, diagnostic migration, and prognostic interpretation when applied to a national registry remains unknown.
Methods:
Using adult heart transplant data from the United Network for Organ Sharing (September 2023 to June 2025), we applied the previous primary graft dysfunction (PGD) and updated early graft dysfunction (EGD) criteria with registry-adapted operationalization, quantified diagnostic migration between frameworks, and compared post-transplant outcomes across reclassified groups using Kaplan-Meier analyses.
Results:
Among 2482 recipients, left ventricular dysfunction was identified in 334 (13.5%) under the previous PGD framework versus 11 (0.4%) under the updated EGD framework, representing a 96.7% relative reduction. Only 8 cases retained identical severity grading across both frameworks. Most discordant cases failed to meet hemodynamic criteria despite a left ventricular ejection fraction ≤40%. Notably, 184 recipients previously classified as severe PGD-left ventricular (LV) no longer met EGD-LV criteria yet had significantly higher mortality than recipients without graft dysfunction (20.1% versus 6.2%; P < 0.001). Right ventricular (RV) dysfunction incidence changed modestly (PGD-RV: 32 [1.3%]; EGD-RV: 28 [1.1%]).
Conclusions:
The updated EGD framework reclassified most previous PGD-LV cases as non-EGD, yet many reclassified recipients remained at elevated risk for graft failure and mortality. These findings reveal a substantial gap between the updated consensus criteria and current registry data, driven largely by failure to satisfy concurrent physiologic criteria required for EGD-LV classification.
