Primary isolated right ventricular failure after heart transplantation: prevalence, right ventricular characteristics, and outcomes (original) (raw)

To determine the prevalence, right ventricular (RV) characteristics, and outcomes of primary isolated RV failure (PI-RVF) after heart transplant (HTX). PI-RVF was defined as (1) the need for mechanical circulatory support post-transplant, or (2) evidence of RVF post-transplant as measured by right atrial pressure (RAP) > 15 mmHg, cardiac index of < 2.0 L/min/m 2 or inotrope support for < 72 h, pulmonary capillary wedge pressure < 18 mmHg, and transpulmonary gradient < 15 mmHg with pulmonary systolic pressure < 50 mmHg. PI-RVF can be diagnosed from the first 24-72 h after completion of heart transplantation. A total of 122 consecutive patients who underwent HTX were reviewed. Of these, 11 were excluded because of secondary causes of graft dysfunction (GD). PI-RVF was present in 65 of 111 patients (59%) and 31 (48%) met the criteria for PGD-RV. Severity of patients with PI-RVF included 41(37%) mild, 14 (13%) moderate, and 10 (9%) severe. The median onset of PI-RVF was 14 (0-49) h and RV recovery occurred 5 (3-14) days after HTX. Severe RV failure was a predictor of 30-day mortality (HR 13.2, 95% CI 1.6-124.5%, p < 0.001) and post-transplant dialysis (HR 6.9, 95% CI 2.0-257.4%, p = 0.001). Patients with moderate PI-RVF had a higher rate of 30-day mortality (14% vs. 0%, p = 0.014) and post-operative dialysis (21% vs. 2%, p = 0.016) than those with mild PI-RVF. Among patients with mild and moderate PI-RVF, patients who did not meet the criteria of PGD-RV had worsening BUN/ creatinine than those who met the PGD-RV criteria (p < 0.05 for all). PI-RVF was common and can occur after 24 h post-HTX. The median RV recovery time was 5 (2-14) days after HTX. Severe PI-RVF was associated with increased rates of 30-day mortality and post-operative dialysis. Moderate PI-RVF was also associated with post-operative dialysis. A revised definition of PGD-RV may be needed since patients who had adverse outcomes did not meet the criteria of PGD-RV. Primary graft dysfunction (PGD) is a leading cause of early mortality after heart transplantation 1,2. Right ventricular PGD (PGD-RV) can cause devastating early post-transplant hemodynamic complications requiring mechanical circulatory support 1-5. Primary isolated RV failure (PI-RVF) or PGD-RV is a condition where there is clinical and/or hemodynamic evidence of RVF in the absence of pulmonary hypertension, RV injury, and cardiac allograft rejection 1-5. The pathogenesis of post-heart transplant RV failure is multifactorial and complex 2,4,6-11. Although ischemia during organ preservation, a consequence of brain death and inotrope effect, and reperfusion injury leads to RV ischemic injury and RV failure, the established pathogenesis of this condition is yet to be determined 10,12,13. Currently, PGD-RV is defined as right ventricular (RV) failure restricted to 24 h after surgery 1-5. Invasive hemodynamic evidence of PGD-RV includes elevated right atrial pressure (> 15 mmHg), normal pulmonary capillary wedge pressure (PCWP) (< 15 mmHg), and low cardiac index (CI) (< 2 L/min/ m 2) 1-5. Recently, Alam et al. 14 proposed that the dose and duration of inotropic support can be used to stratify the