Primary Graft Dysfunction in Patients Supported With Durable Left Ventricular Assist Devices Before Heart Transplantation

BACKGROUND: Previous single-center studies identified an association between pretransplant durable left ventricular assist device (LVAD) support and severe primary graft dysfunction (PGD) following heart transplantation (HT). OBJECTIVES: The current study leverages data from the International Consortium on PGD data to identify trends, quantify outcomes, and identify clinical risk factors of high-risk LVAD-supported patients. METHODS: Clinical data and outcomes of interest, including severe PGD, were compared between patients with and without LVAD support at the time of HT. Among LVAD-supported patients, univariate and multivariable logistic regression analysis was performed on a priori defined variables to determine their association with severe PGD. RESULTS: The final analysis included 4,125 transplant recipients from 14 HT centers, receiving donor hearts by the donation after brain death strategy, with 1,091 (26%) patients supported by LVADs before HT. A total of 365 patients (8.6%) developed severe PGD: 7.4% of those patients without LVAD support and 12.7% of those with LVAD support (P < 0.001). Mortality at 1 year was significantly lower among patients with severe PGD who were bridged to transplantation with a durable LVAD: 28.8% (95% CI: 22.0%-37.1%) vs 40.7% (95% CI: 34.6%-47.7%); log-rank P = 0.025). Risk factors for severe PGD among LVAD-supported patients included pre-HT creatinine, ratio of central venous pressure to pulmonary capillary wedge pressure (CVP/PCWP ratio), and overall donor ischemic time. CONCLUSIONS: HT recipients supported by durable LVADs before HT are at increased risk of PGD, but they experience less mortality associated with this post-transplant complication. Surrogates of venous congestion, including pre-HT creatinine and CVP/PCWP ratio, identify high-risk LVAD-supported patients.