Mechanical circulatory support in severe primary graft dysfunction: Peripheral cannulation but not earlier implantation improves survival in heart transplantation

https://doi.org/10.1016/j.healun.2023.03.008Get rights and content

Background

Primary graft dysfunction (PGD) still affects 2% to 28% of heart transplants (HT). Severe PGD requires mechanical circulatory support (MCS) and is the main cause of death early after HT. Earlier initiation has been suggested to improve prognosis but the best cannulation strategy is unknown.

Methods

Analysis of all HT in Spain between 2010 and 2020. Early (<3 hours after HT) vs late initiation (≥3 hours after HT) of MCS was compared. Special focus was placed on peripheral vs central cannulation strategy.

Results

A total of 2376 HT were analyzed. 242 (10.2%) suffered severe PGD, 171 (70.7%) received early MCS and 71 (29.3%) late MCS. Baseline characteristics were similar. Patients with late MCS had higher inotropic scores and worse renal function at the moment of cannulation. Early MCS had longer cardiopulmonary bypass times and late MCS was associated with more peripheral vascular damage. No significant differences in survival were observed between early and late implant at 3 months (43.82% vs 48.26%; log-rank p = 0.59) or at 1 year (39.29% vs 45.24%, log-rank p = 0.49). Multivariate analysis did not show significant differences favoring early implant. Survival was higher in peripheral compared to central cannulation at 3 months (52.74% vs 32.42%, log-rank p = 0.001) and 1 year (48.56% vs 28.19%, log-rank p = 0.0007). In the multivariate analysis, peripheral cannulation remained a protective factor.

Conclusions

Earlier MCS initiation for PGD was not superior, compared to a more conservative approach with deferred initiation. Peripheral compared to central cannulation showed superior 3-month and 1-year survival rates.

Section snippets

Material and methods

We performed an analysis on the Spanish Heart Transplant Registry, a national database registering all HT in Spain. All patients signed an informed consent to collect their anonymized data prospectively. Between January 1, 2010, and December 31 2020, 2905 adult HT were performed in 17 Spanish centers, 2745 > 18 years old. Excluding 55 combined transplants, a total of 2690 single HT from 17 centers were eligible to be analyzed. Three centers in Spain declined participating in the collection of

Results

From 2376 HT included, 504 (21.21%) suffered PGD according to the ISHLT consensus definition, with the diagnosis being made in the first 24 hours after surgery 242 of them, received MCS (48.02%). According to our definition, 171 (70.66%) received early MCS and 71 (29.34%) late MCS. None of the 242 patients with severe PGD, who needed MCS, received a retransplant during the first year of follow-up.

Discussion

To our knowledge, this is the largest cohort of patients with severe PGD reported in literature. In 242 patients with severe PGD, we report that early MCS, as the one initiated intraoperatively or < 3 hours after HT, doesn't improve survival in severe PGD. Remarkably, peripheral cannulation in this setting offers significantly better outcomes after HT compared to central cannulation, which also challenges some evidence from postcardiotomy shock,13 and the scarce available reports in PGD.15

Author contributions

All authors have contributed in the collection of data, analysis, manuscript elaboration and its critical review.

Disclosure statement

The present study has not received any financial aid. Dr González-Vilchez has received support for attending meetings and/or travel expenses from Pfizer and Novartis; Dr Farrero-Torres has received honoraria for lectures and presentations from Astra Zeneca, Boehringuer, Novartis and Vifor and is member of board of the Sociedad Española de Cardiologia and the International Society for Heart and Lung transplantation; Dr Pomares-Varó has received support for attending meetings from Novartis and

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