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Determinantes cambiantes del riesgo de mortalidad después del trasplante de corazón ortotópico identificados mediante
Kinga Bianka Koritsánszky1,2,3, Rita Szentgróti1,2, Ádám Szijártó1,2
1Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary.
Background:
Orthotopic heart transplantation (OHT) remains the gold standard for end-stage heart failure, yet individualized risk assessment for postoperative mortality remains challenging. We aimed to develop and interpret random forest-based models for predicting 30-day and 1-year mortality and to examine whether the key predictors differ between the 30-day and 1-year models.
Methods:
We analyzed 581 patients who underwent OHT between 2012 and 2024. The 30-day and 1-year mortality rates were 9.9% and 17.6%, respectively. Eighty-seven preoperative and forty-eight postoperative variables were considered as input features for model development. Random forest models were trained and validated using five-fold cross-validation, and explainability was assessed using SHapley Additive exPlanations (SHAP).
Results:
Using preoperative features only, the random forest models achieved AUCs of 0.62 (95% CI, 0.48-0.75) for 30-day and 0.67 (95% CI, 0.56-0.78) for 1-year mortality. SHAP analysis revealed that early mortality predictions were primarily driven by features reflecting acute physiological stress-hepatic dysfunction, inflammation, and hemodynamic instability-whereas long-term predictions were increasingly influenced by renal function, metabolic reserve, and frailty. Incorporating postoperative features improved performance (AUC 0.98 [95% CI, 0.97-0.99] and 0.86 [95% CI, 0.80-0.92], respectively), with model predictions dominated by the severity and persistence of organ dysfunction: short-term risk driven by hepatic injury, hemodynamic compromise, and critical illness, and long-term risk by sustained hepatic and renal impairment, metabolic resilience, and duration of circulatory support.
Conclusions:
Random forest models integrating preoperative and immediate postoperative data could predict short- and mid-term mortality after OHT. SHAP analysis demonstrated temporal shifts in the most important predictors, supporting the role of dynamic, data-driven risk assessment in transplant care.
