Heart transplant surgeons face constant pressure to optimize donor-recipient matching amid rising waitlists and advanced therapies like ECMO bridges, yet severe primary graft dysfunction remains a devastating early complication that demands better prediction. 
In the study published in the Journal of Heart and Lung Transplantation, the researchers reviewed the United Network for Organ Sharing database for all isolated adult heart transplants from September 2023 to March 2025, identifying 5,097 recipients and stratifying them into severe primary graft dysfunction (PGD) cases versus controls. 
Severe PGD occurred in 6.6% of patients (338 cases), defined as left or biventricular failure within 24 hours post-transplant requiring mechanical circulatory support. They further split severe PGD into transient cases (TPGD, MCS weaned by 72 hours, 36.7% or 124 patients) and persistent cases (PPGD, still on MCS at 72 hours). 
Key Risk Factors Guide Donor Selection
Pretransplant recipient extracorporeal membrane oxygenation use strongly predicted severe PGD with an adjusted odds ratio of 2.55 (P<0.001), signaling extreme illness severity that heightens ischemia-reperfusion injury risk. Hearts from donation after circulatory death carried an AOR of 2.13 (P<0.001), reflecting warm ischemia challenges despite recent procurement advances. Donor acidemia before recovery showed an AOR of 2.01 (P<0.001), underscoring the need for rigorous donor labs during evaluation. Recipient prior sternotomy history also increased odds with an AOR of 1.83 (P<0.001), likely due to adhesions complicating reperfusion and right ventricular protection.
Survival Gaps Highlight Urgency
The severe PGD cohort suffered markedly lower 3-month survival at 74.4% compared to 96.8% in controls (P<0.001), confirming its role as a leading early mortality driver. Within severe PGD patients, those with transient dysfunction achieved 88.0% 3-month survival, far exceeding the 67.2% in persistent cases (P<0.001), which offers hope for rapid MCS weaning strategies but warns against prolonged support needs.
Refining Transplant Center Practices
Transplant teams should integrate these predictors into matching algorithms, favoring stable ECMO-free recipients and DBD donors when possible, while prioritizing intraoperative myocardial protection like controlled reperfusion. Double-check donor pH and recipient surgical history to tip the scales against PGD.
Future Matching Evolves with Data
Contemporary UNOS data spanning 18 months emphasizes proactive risk mitigation through enhanced donor assessment and recipient optimization, potentially lowering severe PGD rates and boosting short-term outcomes in this vulnerable population.