Severe early graft dysfunction post-heart transplantation: two clinical trajectories and diastolic perfusion pressure as a predictor of mechanical circulatory support.
Lim, Hoong Sern Bhagra, Sai Berman, Marius Kwok, Chun Shing Chue, Colin Ranasinghe, Aaron Pettit, Stephen
Lim, Hoong Sern
Bhagra, Sai
Berman, Marius
Kwok, Chun Shing
Chue, Colin
Ranasinghe, Aaron
Pettit, Stephen
Citations
Altmetric:
Affiliation
Other Contributors
Publication date
2024-09-12
Subject
Collections
Research Projects
Organizational Units
Journal Issue
Abstract
Background: Severe early graft dysfunction (EGD) is defined by mechanical circulatory support (MCS) <24 hours of heart transplantation (HT). We classified severe EGD based on timing of post-HT MCS: ''Immediate'' intra-operative vs ''Delayed'' post-operative MCS (after admission into intensive care unit (ICU) from operating theater). We hypothesized that (1) risk factors and clinical course differ between ''Immediate'' and ''Delayed'' MCS; and (2) diastolic perfusion pressure (DPP=diastolic blood pressure-central venous pressure) and Norepinephrine equivalents (NE=sum of vasopressor doses), as measures of vasoplegia are related to ''Delayed'' MCS.
Methods: Two-center study of 216 consecutive patients who underwent HT. Recipient, donor, vasopressor doses and hemodynamic data at T0 and T6 (on admission and 6 hours after admission into ICU) were collected.
Results: Of the 216 patients, 67 patients had severe EGD (''Immediate'' MCS: n = 43, ''Delayed'' MCS: n = 24). The likelihood of ''immediate'' MCS but not ''delayed'' MCS increased with increasing warm ischemic and cardiopulmonary bypass times on multinomial regression analysis with ''no MCS'' as the referent group. One-year mortality was highest in ''Immediate'' MCS vs ''no MCS'' and ''delayed'' MCS (34.9% vs 3.4% and 8% respectively, p < 0.001). Of the patients who had no immediate post-transplant MCS, DPP and NE at T6 were independently associated with subsequent ''delayed'' MCS. Sensitivity and specificity of NE≥ 0.2 mcg/kg/min for ''Delayed'' MCS were 71% and 81%. Sensitivity and specificity of DPP of ≥40 mmHg for No MCS were 83% and 74%. The discriminatory value of systemic vascular resistance for ''Delayed'' MCS was poor.
Conclusion: Risk factors and 1-year survival differed significantly between ''Immediate'' and ''Delayed'' post-HT MCS. The latter is related to lower DPP and higher NE, which is consistent with vasoplegia as the dominant pathophysiology.
Citation
Lim HS, Bhagra S, Berman M, Kwok CS, Chue C, Ranasinghe A, Pettit S. Severe early graft dysfunction post-heart transplantation: Two clinical trajectories and diastolic perfusion pressure as a predictor of mechanical circulatory support. J Heart Lung Transplant. 2025 Feb;44(2):161-170. doi: 10.1016/j.healun.2024.09.002. Epub 2024 Sep 12.
Type
Article