Primary graft failure after heart transplantation: the importance of donor pharmacological management.
BACKGROUND
Primary graft failure (PGF) remains the strongest determinant of perioperative mortality after heart transplantation (HT). Donor management may play an important role in the incidence of PGF.


METHODS
Multivariate analysis was used to identify PGF determinants after HT. Donor and recipient data were analyzed together with preharvest management information and perioperative results. PGF was defined as the need for mechanical circulatory support immediately post-HT.


RESULTS
Isolated HT was performed in 54 consecutive patients from January 2006 to June 2009. PGF occurred in 11 (20%) patients. Upon univariate analysis, preoperative mean pulmonary arterial pressure was significantly higher among patients developing PGF (P=.02). The donors for PGF patients had more often been managed with high inotropic support (dopamine>10 microg/kg/min and/or alpha agonists>0.06 microg/kg/min; P=.008). In contrast, death for head trauma was more common among donors for patients who did not develop PGF (P=.02). In-hospital mortality was 13% (7/54); 71% of these deceased patients displayed PGF (5/7). Upon multivariate analysis, preharvest high donor inotropic support was the strongest determinant of PGF (P=.01, odds ratio [OR]=7.5). Donor death due to head trauma showed a protective effect against PGF (P=.03, OR=0.1).


CONCLUSIONS
PGF remains a lethal perioperative complication despite modern tools for prompt cardiac mechanical assistance. As a result of the organ shortage, many centers accept marginal hearts assuming that donor hemodynamic management shows a reduced impact on PGF. We suggest a timely evaluation of the hazards for PGF whenever high inotropic support is used, especially among donors dying for causes other than head trauma.
D'Ancona
G
G
Department of CT Surgery, Mediterranean Institute for Transplantation and Advanced Therapies, University of Pittsburgh Medical Center, Palermo, Italy. gdancona@ismett.edu
Santise
G
G
Falletta
C
C
Pirone
F
F
Sciacca
S
S
Turrisi
M
M
Biondo
D
D
Pilato
M
M
D000328:Adult; D000410:Alanine Transaminase / Q000097:blood; D001219:Aspartate Aminotransferases / Q000097:blood; D002102:Cadaver; D005260:Female; D016027:Heart Transplantation / Q000009:adverse effects* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007431:Intraoperative Complications / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D009926:Organ Preservation / Q000379:methods; D012044:Regression Analysis; D012189:Retrospective Studies; D014019:Tissue Donors; D017211:Treatment Failure; D014655:Vascular Resistance
D001219:Aspartate Aminotransferases; D000410:Alanine Transaminase