Graft dysfunction after orthotopic cardiac transplantation
- Michael X Pham, MD, MPH
Michael X Pham, MD, MPH
- Medical Director of the Center for Advanced Heart Failure Therapies
- California Pacific Medical Center
The development of ventricular dysfunction after cardiac transplantation, which can be systolic, diastolic, or mixed, should be of major concern. The causes of graft dysfunction in the transplanted heart can be different, more ominous, and in some cases more responsive to treatment than those seen in the native heart. As a result, familiarity with the potential etiologies, coupled with an aggressive and systematic approach, is essential to identify the etiology and begin prompt treatment.
Graft dysfunction can occur as early as the intraoperative period or can develop many years after transplantation. The timing of graft dysfunction (days, weeks to months, or years post-transplantation) is one of the most important clues to establish a diagnosis. Graft dysfunction may present as either heart failure with preserved or reduced ejection fraction, asymptomatic ventricular dysfunction, or by elevated intracardiac filling pressures or depressed cardiac output on right heart catheterization. It can affect the right, left, or both ventricles.
The most common causes of graft dysfunction after transplantation include primary graft dysfunction, which typically manifests within 24 hours after surgery; cardiac allograft rejection, which is more common during the first 6 to 12 months post-transplantation; and cardiac allograft vasculopathy, which can occur at any time. Diagnostic procedures such as endomyocardial biopsy, echocardiography, and coronary angiography are important tools in elucidating the etiology, but all these studies have their limitations. (See "Acute cardiac allograft rejection: Diagnosis" and "Endomyocardial biopsy".)
EARLY GRAFT DYSFUNCTION
Early allograft dysfunction can be apparent in the intraoperative period or can develop within 24 hours after transplant surgery. It can manifest as left ventricular (LV) dysfunction, isolated right ventricular (RV) dysfunction, or biventricular dysfunction, and it is associated with significantly increased 30-day and one-year mortality. Early graft dysfunction is classified as primary or secondary graft dysfunction according to the suspected etiology.
Primary graft dysfunction — Primary Graft Dysfunction (PGD) is currently defined as LV, RV, or biventricular dysfunction that occurs within 24 hours after surgery and is not associated with a discernible cause such as hyperacute rejection, pulmonary hypertension, or uncontrolled intraoperative bleeding resulting in massive blood product transfusions and prolonged graft ischemic time . Prior to the development of a standardized definition for PGD, a survey of 47 international heart transplant centers reported an incidence of PGD of 7.4 percent among 9901 patients who underwent heart transplantation between January and March 2013. The majority of centers required an LV ejection fraction of ≤40 percent and/or the use of mechanical support as criteria for PGD. Mortality among patients reported in this survey was 30 percent at 30 days and 35 percent at one year, and the most common causes of 30-day mortality were multiorgan failure in 70 percent of patients, graft failure in 20 percent, and sepsis in 10 percent .
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- EARLY GRAFT DYSFUNCTION
- Primary graft dysfunction
- - Ischemic and reperfusion injury during surgery
- - Suboptimal donor heart
- - Treatment
- Secondary graft dysfunction
- - Hyperacute rejection
- - Treatment
- LATE GRAFT DYSFUNCTION
- - Diagnosis
- Cardiac allograft vasculopathy
- Acute myocarditis
- Nonspecific allograft dysfunction
- Recurrent myocardial disease
- INFORMATION FOR PATIENTS