Can J Cardiol. 2025 Oct 31:S0828-282X(25)01290-5. doi: 10.1016/j.cjca.2025.10.031. Online ahead of print.
ABSTRACT
Primary graft dysfunction (PGD) occurs in nearly 8-10% of heart transplant (HT) recipients, and is the most consequential early complication with an associated reduction in 1 year survival from 95% to 75%. The biological mechanisms underpinning PGD are the subject of ongoing investigations, and thus recognizing, preventing, and treating PGD remain elusive goals. The present expert review summarizes salient developments in both the prediction and management of PGD. The ISHLT consensus definition and its severity was developed over a decade ago. Since then, a significant volume of literature has attempted to elucidate risk factors for PGD at the donor, recipient, and procedural level. Importantly, updated international consensus guidelines, currently in press, have revisited and modernized the definitions and grading of PGD to reflect contemporary practice. Though previously validated prediction tools have performed poorly in contemporary datasets, more updated and clinically relevant models have been developed by leveraging multi-national data and machine learning algorithms. Translational research has identified several donor and recipient biomarkers that promise to revolutionize current prediction paradigms. With respect to the prevention of PGD, novel preservation systems have yielded encouraging early data for expanding the potential donor pool while reducing risk of PGD, but vigorous assessment through randomized trials is still lacking. Finally, while the mainstay of PGD management remains the use of vasoactive medications and mechanical circulatory support, there have been recent publications on pharmacological and non-pharmacological treatments for PGD that may reduce the clinical impact of this deadly complication. While there remains a significant need to reduce the burden of PGD following HT, evolving literature suggests that with enough validated data, PGD may be a predictable phenomenon, the burden of which can be mitigated by targeted interventions at discrete time points. Performance of multicentre, prospective, and when possible randomized, trials will be crucial to ensuring that future clinical practice is guided by robust evidence.
PMID:41177377 | DOI:10.1016/j.cjca.2025.10.031