Marginal cardiac allografts do not have increased primary graft dysfunction in alternate list transplantation.
BACKGROUND
Clinical success with modern heart transplantation (HT) has led to the development of an alternate list (AL) HT strategy, matching marginal cardiac allografts with recipients who do not meet standard criteria for HT. Marginal allografts may be at an increased risk for primary graft dysfunction (PGD), the leading cause of early mortality after HT.(1) The incidence of PGD in AL HT relative to standard list (SL) HT has not been evaluated, and may contribute to the greater mortality associated with AL HT.(2) The objective of this study was to determine the incidence of and predictors for PGD.


RESULTS
A retrospective analysis was performed on 260 consecutive adult patients undergoing either SL HT (n=207) or AL HT (n=53) at our institution from 1/2000 to 1/2005. PGD was defined by requirement for mechanical circulatory support immediately post-HT or more broadly as the need for either mechanical support or high-dose inotrope (epinephrine > or = 0.07 microg/kg/min). Donor hearts allocated to AL recipients were turned down for SL HT for reasons that included coronary disease, left ventricular dysfunction or hypertrophy, and high-dose inotropic requirement. AL HT recipients were significantly older, with a higher proportion of diabetes mellitus and ischemic cardiomyopathy. Both groups experienced a similar incidence of significant rejection, but overall mortality was higher in the AL HT group. (2) The incidence of PGD did not differ between AL and SL HT recipients. Pre-transplant VAD and prolonged total ischemic times (> or = 4.5 hours) were independent predictors of PGD.


CONCLUSIONS
Select marginal donor hearts used in AL HT do not have an increased incidence of PGD. Pre-transplant VAD and prolonged ischemic times are more important determinants of PGD. These data support continued aggressive utilization of marginal donor hearts in AL HT.
Lima
Brian
B
DUMC Box 3043, Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
Rajagopal
Keshava
K
Petersen
Rebecca P
RP
Shah
Ashish S
AS
Soule
Beth
B
Felker
G Michael
GM
Rogers
Joseph G
JG
Lodge
Andrew J
AJ
Milano
Carmelo A
CA
D000328:Adult; D000368:Aged; D002316:Cardiotonic Agents / Q000627:therapeutic use; D005260:Female; D006084:Graft Rejection / Q000453:epidemiology; D006085:Graft Survival; D006331:Heart Diseases / Q000453:epidemiology; D006333:Heart Failure / Q000188:drug therapy / Q000453:epidemiology* / Q000209:etiology / Q000601:surgery; D016027:Heart Transplantation / Q000592:standards; D006353:Heart-Assist Devices; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology* / Q000209:etiology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012306:Risk; D014019:Tissue Donors; D009927:Tissue and Organ Procurement / Q000592:standards*; D014184:Transplantation, Homologous; D016896:Treatment Outcome; D014850:Waiting Lists
D002316:Cardiotonic Agents