Comparable Rates of Severe Primary Graft DysfunctionAfter Heart Transplantation in Recipients With Prior LVAD or Other Cardiac Surgery: The Burden of Surgical Reentry.

INTRODUCTION The use of durable left ventricular assist device (dLVAD) as a bridge to heart transplantation (HTx) is a risk factor for severe primary graft dysfunction (sPGD). Whether the intrinsic properties of the device itself, or mediastinal reentry at the time of HTx, are responsible for this deadly complication remains unknown.

Methods

We conducted a retrospective cohort study using the United Network for Organ Sharing database from September 2023 through May 2025 comparing patients with a dLVAD to those with prior non-dLVAD cardiac surgery and no prior cardiac surgery. The primary outcome was development of severe PGD; secondary outcomes included non-sPGD complications and 180-day survival. Multivariable logistic regression, multivariable Cox models, and propensity score matching were used for analysis.

Results

In sum, 3406 patients were included. A total of 219 (6.4%) recipients experienced sPGD. Rates were similarly elevated among those with dLVAD and prior non-dLVAD cardiac surgery (11.1 vs. 10.9%, adjusted odds ratio (aOR) 0.81 [95% CI 0.50-1.32]) but significantly higher than those with no prior surgery (11.1 vs. 4.2%, aOR 2.17 [95% CI 1.50-3.13]). Rates of post-operative dialysis were similar between dLVAD and prior non-dLVAD cardiac surgery (21.5 vs. 22.5%, aOR 0.93, [95% CI 0.65-1.33]), but significantly higher than those with no prior surgery (21.5 vs. 13.7%, aOR 1.83 [95% CI 1.44-2.32]). 180-day mortality was comparable between dLVAD and prior non-dLVAD cardiac surgery (8.5 vs. 8.5%, adjusted hazard ratio (aHR) 0.98 [95% CI 0.58-1.65]) but significantly higher than those with no prior cardiac surgery (8.5 vs. 4.2%, aHR 2.13 [95% CI 1.46-3.13]). Propensity score matching confirmed these results.

Conclusions

Recipients bridged with dLVAD display phenotypic similarity to those with prior non-dLVAD cardiac surgery postoperatively, indicating that mediastinal reentry likely plays a large role in the pathophysiology of sPGD in bridging with dLVAD.