Primary graft dysfunction after LVAD bridge-to-transplant: a systematic review and meta-analysis
T Phatinavin, T Kajitkam, N Tokavanich, R ChokesuwattanaskulAbstract
Background
Primary graft dysfunction (PGD) remains a major determinant of early morbidity and mortality following heart transplantation. Durable left ventricular assist devices (LVADs) are frequently used as bridge-to-transplant (BTT) therapy; however, their impact on PGD risk has not been clearly defined in contemporary practice. The aim of this systematic review and meta-analysis was to evaluate whether the use of LVAD as bridge-to-transplant therapy increases the risk of primary graft dysfunction in adult heart transplant recipients.
Methods
From inception to November 2025, a comprehensive search for prospective and retrospective studies in MEDLINE, Embase, Cochrane, and Google Scholar was conducted. Studies were included if they reported data on the Odds Ratio(OR) or the incidence of primary graft dysfunction in LVAD bridge to transplant patients. Data from each study were combined using the random-effects model. Results were expressed as odds ratio (OR) and incidence (%) with 95% confidence interval (CI).
Result
Nineteen observational studies encompassing 58,383 heart transplant recipients were included. Among 11,249 LVAD BTT patients from 17 studies, the pooled incidence of PGD was 14.1% (95% CI: 9.5%–19.5%). In comparative analyses of 14 studies (n = 16,722), LVAD BTT was associated with higher odds of PGD compared with medically managed recipients (OR 1.61, 95% CI: 1.20–2.15; I² = 66%). Meta-regression demonstrated a negative association between recipient ischemic cardiomyopathy and PGD incidence. An analysis of device types (HM3, HeartMate II, HVAD) showed differential results. Among LVAD-supported recipients, pre-transplant amiodarone use was associated with increased PGD risk (OR 2.37, 95% CI: 1.13–4.96).
Conclusion
In patients undergoing heart transplantation, LVAD bridge-to-transplant support is associated with a significantly increased risk of primary graft dysfunction. Modifiable factors, including pre-transplant amiodarone exposure, may further influence PGD risk in this population. These findings highlight the importance of individualized perioperative risk assessment and optimization in LVAD-supported transplant candidates.