Incidence and Impact of Primary Graft Dysfunction in Adult Heart Transplant Recipients: A Systematic Review and Meta-Analysis

Purpose Primary graft dysfunction (PGD) is a life-threatening complication and a leading cause of early mortality post heart transplant (HTx). Recent studies evaluating the incidence and prognosis of PGD have benefited from the ISHLT 2014 Consensus Report which clearly defines this condition. Our objective was to systematically review all studies that reported the incidence of PGD in adult HTX recipients since 2014 to more accurately identify its incidence and impact on mortality. Methods We conducted a systematic search of the literature in Medline in October 2019. We included studies that reported the incidence of PGD in adult HTx recipients, based on the 2014 ISHLT Consensus Report. Two independent reviewers screened citations and performed data abstraction. We used a random effects meta-analysis to pool the incidence among HTx recipients, as well as the rate of mortality among those who developed PGD. We applied the GRADE instrument for incidence and mortality separately to determine our certainty in the pooled estimates. Results Of 127 publications screened, we included 36 observational studies. HTx recipient age ranged from 24-69 years and 24% were female. Donor age ranged from 23-50 years, sex mismatch occurred in 21% and ischemic time ranged from 86-273 minutes. We observed similar incidence for each severity of PGD but increasing risk of 1-year mortality (Table 1). Estimates of 30-day mortality were only available for severe PGD: 39% (95% CI 32% - 46%, 9 studies, high certainty). Conclusion Based on the 2014 ISHLT criteria, the published pooled incidence of PGD is low, and its prognosis is poor. The extensive heterogeneity in incidence and mortality suggests inconsistencies in the recognition and/or management of PGD. This represents an opportunity for improved risk stratification, prevention and management strategies.