Clinical Characteristics and Outcomes Associated With Immediate Versus Delayed Presentation of Severe Primary Graft Dysfunction After Heart Transplantation: Does Timing Matter?

Background Severe left ventricular/biventricular primary graft dysfunction (PGD‐LV) continues to be a major contributor to 30‐day mortality post‐heart transplantation (HTx). In patients with severe PGD‐LV, two distinctive presentation phenotypes are encountered: an “immediate PGD” (IP), where patients fail to wean from cardiopulmonary bypass (CPB), or a “delayed PGD” (DP) following successful weaning from CPB and/or transfer from the operating room. Data on these phenotypes' incidence, associated characteristics, and outcomes remain limited. Therefore, we assessed patient characteristics and 1‐year post‐HTx outcomes associated with IP versus DP. Methods Between 2010 and 2022, we included 47 HTx patients with severe PGD‐LV. Patients were divided into those with IP ( n = 16) and those with DP ( n = 31). Endpoints included 30‐day and 1‐year survival, as well as 1‐year freedom from any‐treated rejection (ATR), acute cellular rejection (ACR), antibody‐mediated rejection (AMR), biopsy‐negative rejection (BNR), cardiac allograft vasculopathy (CAV), non‐fatal major adverse cardiac events (NF‐MACE), and freedom from left ventricular dysfunction (LVD). Results Compared to patients with DP, those with IP had a higher prevalence of pre‐HTx sensitization (56.3% vs. 19.4%, p = 0.01) and tended to receive hearts from older donors (47.5 vs. 34 years, p = 0.055). They had decreased survival rates at 30 days (50% vs. 77.4%, p = 0.043) and 1‐year post‐HTx (31.2% vs. 61.1%, p = 0.029). No significant differences were recorded in 1‐year freedom from CAV, ATR, ACR, AMR, BNR, NF‐MACE, or LVD. Conclusion Immediate presentation of severe PGD‐LV appeared to be associated with pre‐HTx sensitization and use of older donor hearts and conferred a worse post‐HTx survival.