Differential impact of pre-transplant hemodynamic optimization strategies on postoperative extracardiac outcomes

Abstract Background The influence of pre-transplant hemodynamic support on extracardiac recovery after heart transplantation remains uncertain. We assessed whether temporary mechanical circulatory support (MCS) type and preoperative hemodynamic instability affect extracardiac outcomes. Methods We retrospectively studied 136 patients who underwent transplantation at status 2 (2022–2024). Patients were stratified by pre-transplant MCS: none, intraaortic balloon pump (IABP), Impella, or durable ventricular assist device (VAD). The primary endpoint was an extracardiac complication (ECC) score, a weighted composite including ventilation 72h, tracheostomy, renal replacement therapy, ICU stay 10d, vasoplegia, discharge to rehab/LTAC, and 30-day mortality. A hemodynamic instability (HI) score (0–6; CI ≤2.2, SBP 90, PP 30, MAP 60, PCWP 15, API 2) was also calculated. Negative binomial regression assessed associations. Results Compared with no MCS, Impella bridging was associated with a markedly lower ECC score (IRR 0.31, 95% CI 0.12–0.77, p=0.014), as was IABP (IRR 0.43, 95% CI 0.18–0.99, p=0.037) after adjusting for pre-transplant HI score. VAD support conferred no difference (IRR 1.04, 95% CI 0.33–3.68). HI score alone was not independently predictive (IRR 1.04 per point, p=0.60) of ECC score. Conclusions Patients that achieved hemodynamic stability with help of pre-transplant MCS experienced fewer post-transplant extra-cardiac complications. Clinical Implications: Choice of bridging strategy, especially Impella or IABP, may optimize extracardiac recovery post heart transplant and should be integrated into transplant decision-making.