Ishlt Consensus
Report from a consensus conference on primary graft dysfunction after cardiac transplantation

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Although primary graft dysfunction (PGD) is fairly common early after cardiac transplant, standardized schemes for diagnosis and treatment remain contentious. Most major cardiac transplant centers use different definitions and parameters of cardiac function. Thus, there is difficulty comparing published reports and no agreed protocol for management. A consensus conference was organized to better define, diagnose, and manage PGD. There were 71 participants (transplant cardiologists, surgeons, immunologists and pathologists), with vast clinical and published experience in PGD, representing 42 heart transplant centers worldwide. State-of-the-art PGD presentations occurred with subsequent breakout sessions planned in an attempt to reach consensus on various issues. Graft dysfunction will be classified into primary graft dysfunction (PGD) or secondary graft dysfunction where there is a discernible cause such as hyperacute rejection, pulmonary hypertension, or surgical complications. PGD must be diagnosed within 24 hours of completion of surgery. PGD is divided into PGD-left ventricle and PGD-right ventricle. PGD-left ventricle is categorized into mild, moderate, or severe grades depending on the level of cardiac function and the extent of inotrope and mechanical support required. Agreed risk factors for PGD include donor, recipient, and surgical procedural factors. Recommended management involves minimization of risk factors, gradual increase of inotropes, and use of mechanical circulatory support as needed. Retransplantation may be indicated if risk factors are minimal. With a standardized definition of PGD, there will be more consistent recognition of this phenomenon and treatment modalities will be more comparable. This should lead to better understanding of PGD and prevention/minimization of its adverse outcomes.

Section snippets

Clinical background

Although survival after cardiac transplantation has been improving for the last 2 decades, whether the incidence and mortality from PGD has followed suit is unclear from the literature.2, 3, 4 This lack of clarity stems not from the amount of research conducted on the topic of PGD but instead from the lack of standardization of diagnostic criteria. Parameters such as requirement of inotropic support, left ventricular (LV) ejection fraction (LVEF), and requirement of cardiac mechanical support

Epidemiology and outcomes: Josef Stehlik

Although ascertainment of the exact incidence of PGD from registry data is not possible, these data provide us with important information about the epidemiology and the clinical characteristics associated with PGD. Data of interest available in the ISHLT Transplant Registry (Registry) include donor, recipient, and transplant event characteristics, early mortality, and the causes of death.2, 4

Examination of early mortality after heart transplant documented in the Registry reveals that 66% of the

PGD Experience in select transplant centers

The consensus conference also consisted of presentations from high-volume transplant centers regarding their experience and their management of PGD. These are summarized in Table 4. These presentations provided a basis for further discussion on treatment of PGD and use of inotropic agents and mechanical circulatory support.

Breakout sessions from the PGD consensus conference

Although specific background presentations took place in the morning of the consensus conference, the afternoon was devoted to breakout discussion sessions. The participants were divided into 3 groups to allow for further discussion and interaction. Each group included a mix of cardiologists, cardiac surgeons, pathologists, and immunologists. Clinical issues regarding recognition, management, and prevention of PGD were discussed similarly amongst participants in the 3 groups. All points of

Summary of the consensus statements on PGD

After the breakout sessions, the reconvened conference focused on reaching consensus on salient topics pertaining to diagnosis and management of PGD. The discussion throughout the day had made it clear that standardization of the definition of PGD was one of the most important requirements of the conference. This would allow easier recognition of the phenomenon and communication between clinicians. It was decided that graft dysfunction be distinguished as primary graft dysfunction (PGD) as

Consensus statements

  • 1.

    Graft dysfunction is to be classified into PGD or secondary graft dysfunction where there is a discernible cause such as hyperacute rejection, pulmonary hypertension, or known surgical complications (e.g., uncontrolled bleeding; Table 5).

  • 2.

    The diagnosis of PGD is to be made within 24 hours after completion of the cardiac transplant surgery.

  • 3.

    PGD is to be categorized into PGD-LV or PGD-RV (Table 6).

  • 4.

    A severity scale for PGD-LV will include mild, moderate or severe grades based on specified criteria (

Disclosure statement

The authors express their deepest appreciation and gratitude to Christine Sumbi for organizing and planning this conference.

This conference was jointly funded by the ISHLT and the Cedars-Sinai Heart Institute.

Jon Kobashigawa, MD, is scientific medical advisor to TransMedics Inc and Novartis, and discloses research grants and research support from Novartis and XDx Inc. Fardad Esmailian, MD, is a member of steering committee for PROCEED II trial. Jignesh Patel, MD, PhD, discloses research grants

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