Why the study?
Severe primary graft dysfunction is reported in 5-10% of heart transplant recipients and carries high early mortality, prompting this review to estimate its pooled incidence and mortality and identify pre-transplant risk factors.
Meta-Analysis (n=12,001)
Severe primary graft dysfunction affects approximately 11.1% of heart transplant recipients with an early mortality rate of 38.4%, and is significantly associated with pre-transplant mechanical circulatory support (ECMO or VAD/LVAD).
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MCS-bridged recipients warrant close PGD monitoring; extends incidence data but leaves open prospective mitigation trials.
Severe primary graft dysfunction (PGD) is reported in 5â"10% of heart transplant recipients and carries high early mortality. This review aimed to estimate the pooled incidence and mortality of severe PGD and to identify pre-transplant risk factors. PubMed, Scopus, and Embase were systematically searched from 2000 to February 2026 for observational studies reporting the incidence, mortality, or risk factors of severe PGD (International Society for Heart and Lung Transplantation [ISHLT] grade 3 or equivalent) after heart transplantation. Pooled proportions for incidence and mortality were calculated in OpenMeta[Analyst] using a random-effects model with the Freemanâ"Tukey double-arcsine transformation. Total 20 observational studies (12,001 recipients) met eligibility. The pooled incidence of severe PGD was 11.1% (95% CI, 8.0â"14.0%; I² ≤ 93%) and pooled mortality among patients with severe PGD was 38.4% (95% CI, 20.0â"58.0%; I² ≤ 96%). Pre-transplant extracorporeal membrane oxygenation (ECMO) was associated with severe PGD (OR 2.49; 95% CI, 1.43â"4.32; p ≤ 0.001; I² ≤ 67%), as was pre-transplant ventricular assist device (VAD/LVAD) support (OR 1.49; 95% CI, 1.11â"1.99; p ≤ 0.007; I² ≤ 26%). Donor ischemic time was not significantly associated with severe PGD (OR 1.02; 95% CI, 0.99â"1.05; p ≤ 0.14; I² ≤ 83%). Severe PGD affects approximately one in nine heart transplant recipients and carries an early mortality of nearly 40%. Pre-transplant mechanical circulatory support (ECMO or durable VAD) is an important predictor, whereas donor ischemic time was not significantly associated in pooled data.
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Alshehri et al. (2026) conducted a meta-analysis in Severe primary graft dysfunction (PGD) after heart transplantation (n=12,001). Pre-transplant extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD/LVAD) support vs. No pre-transplant mechanical circulatory support was evaluated on Incidence and mortality of severe primary graft dysfunction (PGD), and association with pre-transplant ECMO (OR 2.49, 95% CI 1.43-4.32, p=≤ 0.001).
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