Primary Heart Graft Failure (2010)

Heart transplantation is, without doubt, an effective method of treating heart failure patients crippled and fatally threatened by drug-resistant, severe heart failure. Perioperative (or 30-day) mortality is of the order of 8% and is dominated by primary graft failure (PGF). Its incidence, among those dying early after heart transplantation, is of the order of 20% to 40% (1). PGF competes with infection, hemorrhage, multiorgan failure, and acute rejection as a cause of perioperative death. It probably develops as a result of insufficient power of the heart to manage the demands of the new circulation (too small a heart, a heart with myocardial damage, and excessive ventricular after load). But how to recognize PGF? Russo et al., in this journal, offer a hard definition of PGF, through necessity, in their retrospective analysis of 16,716 patients. They have taken it from the United Network for Organ Sharing heart transplant database during an 8-year period. Their definition required PGF to lead to death or retransplantation within the first 90 days after heart transplantation. Russo et al. found 1555 deaths in this group (9%). Three hundred sixty-four patients died and 60 were retransplanted with the label of PGF; an incidence of 23% of those dying in the first 90 days and 2% of all who underwent heart transplantation. Extending this postoperative period of review to 90 days would tend to reduce the incidence of PGF as a cause of death in which acute rejection and infection dominate in the 30- to 90-day period after heart transplantation (2). In addition, this hard definition can be expected to reduce the incidence too, so that we can accept PGF as defined by these authors to be a conservative estimate at 25% of all early deaths. Others have addressed PGF in the past. Taking a large series, we find that Lima et al. (1) offered high inotrope (0.07 μg/kg/min of epinephrine) or need for ventricular assist devise (VAD) after transplantation as a definition of PGF. Within the first 30 days after heart transplantation, PGF complicated 23% to 26% of all reported deaths in this series. They found PGF to be associated with pretransplant VAD support for the patient or a donor heart ischemic time of greater than 4.5 hr. The presence of PGF translated into a 14% to 16% greater mortality at 30 days and 15% greater mortality at 1 year. When considering graft failure, others have shown that reduced contractility, loss of contractile reserve, and increased right ventricular volume are common after heart transplantation (3), emphasizing the need for clarity over definition of PGF. With all this in mind, Russo et al. generally offer well-numbered variables associated with PGF to include ischemic time, donor age and gender, multiorgan transplantation, transplant center volume, extracorporeal membrane oxygenation support, cause of heart failure, and redo heart transplantation. The effect of ischemic time on PGF increased both with shorter and longer ischemic time. A short ischemic time as a factor to be associated with the development of PGF is counter-intuitive and perhaps should be viewed in the knowledge of small numbers despite the size of this study. It is also sobering to imagine the circumstances that would lead to an ischemic time of less than 1 hr. Similarly, multiorgan donation is notable in that simultaneous kidney and pancreas donation seemed to be protective against PGF but lung donation is associated with its development. Russo et al. offer an interesting article with some insights into potential associations with PGF at the time of heart transplantation. Enjoy this contribution but read it understanding the shortcomings of the eccentric metrics and hard definition of PGF used. So where do we go with this information? Others have shown that the presence of PGF is a predictor of worse survival at 30 days and thereafter. Therefore, it is entirely reasonable to encourage the heart transplant community to develop a preoperative PGF scoring system to assess the risk of its development after heart transplantation in very much the same way as lung transplant colleagues have done (4).