Donor pharmacological hemodynamic support is associated with primary graft failure in human heart transplantation

Abstract

The aim of this study was to test the impact of donor and recipient characteristics on the development of primary graft failure (PGF) after heart transplantation (HT) by focusing on the donor's inotropic support. Heart donors and matched recipients data were prospectively collected. Univariate and multivariate analyses were used to determine independent predictors for PGF and peri-operative mortality. The donor's high inotrope requirement was defined as sustained need for dopamine exceeding 10 microg/kg/min and/or alpha agonists exceeding 0.06 microg/kg/min. PGF instead was defined as need for immediate post-HT mechanical circulatory support. Since 2006, we have performed 37 HTs. PGF occurred in six patients (16.2%). Although four patients (66.6%) were weaned off circulatory support, two of them (33.3%) died on mechanical assistance. Total in-hospital mortality was 10.8% (4/37). Upon multivariate analysis, pre-harvesting donor high inotrope dosage was the major determinant for PGF (P=0.03, OR=10.8). Given the organ shortage, many centers accepted marginal hearts assuming the donor's pre-harvest hemodynamic managing has a reduced impact on PGF development. As PGF remains the most lethal postoperative complication, the hazards should be carefully considered when using pre-harvesting high inotrope infusion rates.

High-dose catecholamine donor support and outcomes after heart transplantation

“…[20][21][22] In addition, several studies have shown associations between norepinephrine donor support and PGD. [23][24][25] Contrary to these data, it has been hypothesized that avoidance of high-dose catecholamine support is not of primary importance during donor management, based on the assumption that individuals' endogenous catecholamine levels, and therefore tolerance toward administered catecholamines, vary widely. 26 Indeed, several clinical studies have concluded that norepinephrine doses are not associated with adverse outcomes after HTx.…”

Hydrocortisone Supplementation Enhances Hemodynamic Stability in Brain-dead Patients

“…Conversely, a recent study has demonstrated that high dose of vasoactive drugs in donor was a major determinant for primary graft failure in heart transplantation. 35 Further evaluation would be useful to evaluate the benefit of the decrease of norepinephrine requirement in donors for cardiac and other transplants. Third, because measurement of the free cortisol concentration is currently not widely available, we measured total plasma cortisol concentration, rather than the protein-bound fraction, whereas the free cortisol is responsible for the physiologic function of the hormone.…”

Usefulness of extracorporeal membrane oxygenation for early cardiac allograft dysfunction

“…2 Abnormal LV function is commonly related to the adrenergic storm in brain-dead donors 3,4 and may be perpetuated by high-level adrenergic inotrope support. 4,5 Hormonal therapies, including triiodothyronine, vasopressin, and methylprednisolone, have been used in an attempt to ameliorate these changes and have improved short-term mortality rates and reduced the rate of early graft dysfunction. 6 Despite these efforts, there remain a proportion of potential donors with persistent LV systolic dysfunction and high inotrope requirements.…”