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RADIAL: A novel primary graft failure risk score in heart transplantation

https://doi.org/10.1016/j.healun.2011.01.721Get rights and content

Background

Primary graft failure (PGF) is the leading cause of early mortality after heart transplantation (HT). Our aim is to propose a working definition of PGF and to develop a predictive risk score.

Methods

PGF was defined by four criteria reflecting significant myocardial dysfunction, severe hemodynamic impairment, early onset after HT, and absence of secondary causes of graft dysfunction. We identified independent risk factors for PGF in a derivation series of 621 HTs and constructed a predictive model. After proving its internal consistency we tested the model in a prospective validation series.

Results

The incidence and lethality of PGF in our series were 9% and 80%, respectively. We identified 6 multivariate risk factors for PGF (Right atrial pressure ≥10 mm Hg, recipient Age ≥60 years, Diabetes mellitus, Inotrope dependence, donor Age ≥30 years, Length of ischemic time ≥240 minutes—i.e., RADIAL). Analysis of isolated right ventricular failure showed similar predictors. The RADIAL score was obtained by adding 1 point for each of these factors present in a given HT. PGF incidence increased significantly as the RADIAL score increased (p < 0.001 for trend). Rates of actual and predicted PGF incidence for RADIAL subgroups showed a good correlation (C-statistic = 0.74). In a prospective validation cohort, RADIAL score kept its predictive ability.

Conclusions

PGF as defined by these criteria showed a high impact on early post-HT mortality in our series. The RADIAL score showed good ability to predict the development of PGF, and could be useful in the prevention and early treatment of this complication.

Section snippets

Patient population

A series of 696 consecutive HTs were performed at our hospital between 1984 and 2006. Data were collected prospectively into a database at the time of HT and then retrospectively reviewed for this study. We excluded 23 patients with a second transplant and 30 patients with transplantation of another organ in combination with HT. We also excluded 22 patients with unusually high pulmonary hypertension before HT (defined by the presence of pulmonary artery systolic pressure >50 mm Hg,

Population data

The main recipient, donor and procedural characteristics are shown in Table 1. PGF, according to our definition, occurred in 56 of 621 HTs (overall incidence 9%). Isolated RV failure occurred in 34 patients (61%), and left (11%) or biventricular (28%) dysfunction was observed in 22 patients (39%).

In addition to intravenous inotropic therapy, 37 HT recipients (66%) received mechanical support. In 27 PGF patients (48%) a VAD was implanted (20 right-sided, 1 left-sided and 6 biventricular

Discussion

PGF is a major cause of death after HT, and is probably the most frustrating for clinicians. Even if PGF is not always the final cause of death in these patients, it often contributes to complications, such prolonged ventilation and ICU stay, which are related to higher mortality rates. Nevertheless, PGF has received little attention in the HT literature. In the 2009 report of the ISHLT registry, PGF was shown to be the main cause of early mortality, accounting for 40% of deaths within 30 days.1

Disclosure statement

This work was supported by the Fundación para la Investigación Biomédica del Hospital Universitario Puerta de Hierro, Red de Investigación Clínica y Básica en Insuficiencia Cardiaca (REDINSCOR) and Beca de Investigación en Trasplante Cardiaco de la Sección de Insuficiencia Cardiaca y Trasplante of the Spanish Society of Cardiology.

The authors have no conflicts of interest to disclose.

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