Right Heart Failure during Support with a Left Ventricular Assist Device is Associated with Primary Graft Dysfunction after Heart Transplantation

Introduction Primary graft dysfunction (PGD) is a devastating complication of heart transplantation that is associated with high rates of morbidity and mortality. Right heart failure (RHF) while on LVAD support may identify patients at higher risk for post-transplant complications. This study investigated the relationship between RHF while on LVAD support and post-transplant outcomes. Methods Patients with durable, continuous-flow LVADs who were transplantated between 2010 and 2016 at Barnes-Jewish Hospital were included. Data collection was performed through retrospective chart review. RHF was defined as the need for right ventricular assist device, the extended use of inotropes for more than 14 consecutive days post-LVAD implant, the need to reinitiate inotropes after 14 days but before 30 days after LVAD, or heart failure requiring medical intervention >30 days after discharge from LVAD implantation. The primary outcome was the incidence of PGD after transplant compared between patients with and without RHF. Secondary outcomes included 30-day and 1-year survival, incidence of vasoplegia, severity of PGD, and outcomes stratified by type of RHF. A multivariate logistic regression model was created and included baseline characteristics differing between groups using a p-value of Results Among the 141 patients included in the study, 41 developed RHF while supported with an LVAD. The cohort had a median age of 58, was mostly male (78.7%), and mostly white (74.5%). Most patients had a non-ischemic cardiomyopathy (57%) and were implanted with a HeartMate II LVAD (84.4%). The RHF group had a higher incidence of donor-recipient weight mismatch (3.0% vs. 14.6%, p=0.018) and lower donor EF (55% vs 60%, p=0.018), with no other significant differences in baseline characteristics. In the RHF cohort, 18 patients developed PGD as compared to 14 patients in the group without RHF (43.9% vs. 14.0%, p Conclusions The results of this study show that patients supported with LVADs who develop early severe or late RHF are at increased risk of PGD and death following cardiac transplantation. Donor factors may further increase the risk of these outcomes and should be carefully assessed in this high-risk group. Given the striking increase in PGD, increased vigilance for PGD and aggressive early hemodynamic support should be anticipated for these patients.