Primary graft failure after heart transplantation: the importance of donor pharmacological management

Abstract

Background: Primary graft failure (PGF) remains the strongest determinant of perioperative mortality after heart transplantation (HT). Donor management may play an important role in the incidence of PGF.

Materials and methods: Multivariate analysis was used to identify PGF determinants after HT. Donor and recipient data were analyzed together with preharvest management information and perioperative results. PGF was defined as the need for mechanical circulatory support immediately post-HT.

Results: Isolated HT was performed in 54 consecutive patients from January 2006 to June 2009. PGF occurred in 11 (20%) patients. Upon univariate analysis, preoperative mean pulmonary arterial pressure was significantly higher among patients developing PGF (P=.02). The donors for PGF patients had more often been managed with high inotropic support (dopamine>10 microg/kg/min and/or alpha agonists>0.06 microg/kg/min; P=.008). In contrast, death for head trauma was more common among donors for patients who did not develop PGF (P=.02). In-hospital mortality was 13% (7/54); 71% of these deceased patients displayed PGF (5/7). Upon multivariate analysis, preharvest high donor inotropic support was the strongest determinant of PGF (P=.01, odds ratio [OR]=7.5). Donor death due to head trauma showed a protective effect against PGF (P=.03, OR=0.1).

Conclusion: PGF remains a lethal perioperative complication despite modern tools for prompt cardiac mechanical assistance. As a result of the organ shortage, many centers accept marginal hearts assuming that donor hemodynamic management shows a reduced impact on PGF. We suggest a timely evaluation of the hazards for PGF whenever high inotropic support is used, especially among donors dying for causes other than head trauma.