title: Early institution of mechanical support improves outcomes in primary cardiac allograft failure.
abstract: BACKGROUND
  Primary graft failure (PGF) is the leading cause of early mortality after cardiac transplantation, accounting for 27.1% of deaths within 30 days. PGF is defined as severe dysfunction of the cardiac allograft without any obvious anatomic or immunological cause. The purpose of this study was to analyze our last 9 years of experience with cardiac transplantation to determine predictors of PGF and the influence on survival of our policy of early institution of mechanical circulatory support (MCS) in these patients.
  
  
  METHODS
  Data on 214 consecutive cardiac transplants performed at The Alfred Hospital between January 1996 and August 2004 were reviewed. PGF was defined as right or left or biventricular failure manifesting as hypotension (systolic blood pressure <90 mm Hg), low cardiac output (cardiac index <2.0 liter/min/m2 and pulmonary capillary wedge pressure >20 mm Hg after coming off cardiopulmonary bypass despite inotropic support of up to 5 mug/min adrenaline and without any other obvious cause for the graft dysfunction.
  
  
  RESULTS
  PGF developed in 51 patients (24%). Significant factors in the development of PGF were long ischemic time, which became significant over 4 hours (odds ratio, 1.43; p = 0.01) and increased donor age (odds ratio, 1.027; p = 0.045). Fifteen patients required mechanical support, and of these, 10 survived to leave hospital.
  
  
  CONCLUSIONS
  PGF is the major cause of early mortality after cardiac transplantation. Significant risks for PGF are long allograft ischemic time and increased donor age. Once the patient has survived 30 days, however, the longer-term survival is not influenced by PGF. Our management strategy of early mechanical support has yielded good outcomes in this population with a high risk of early death.
authors.affiliation: CJOB Cardiothoracic Surgery Unit, The Alfred Hospital, Melbourne, Australia. s.marasco@alfred.org.au
authors.forename: Silvana F
authors.initials: SF
authors.lastname: Marasco
authors.forename: Donald S
authors.initials: DS
authors.lastname: Esmore
authors.forename: Justin
authors.initials: J
authors.lastname: Negri
authors.forename: Michael
authors.initials: M
authors.lastname: Rowland
authors.forename: Andrew
authors.initials: A
authors.lastname: Newcomb
authors.forename: Franklin L
authors.initials: FL
authors.lastname: Rosenfeldt
authors.forename: Michael
authors.initials: M
authors.lastname: Bailey
authors.forename: Meroula
authors.initials: M
authors.lastname: Richardson
mesh_terms: D000367:Age Factors; D001243:Assisted Circulation; D005260:Female; D006331:Heart Diseases / Q000601:surgery; D016027:Heart Transplantation; D006801:Humans; D007511:Ischemia; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D014019:Tissue Donors; D014184:Transplantation, Homologous; D016896:Treatment Outcome