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Original research
Association between routine measures of graft function and mortality in heart transplant recipients
  1. Farid Foroutan1,
  2. Abdullah Malik2,
  3. Lærke Marie Sidenius Nelson3,
  4. Chun-Po Fan Steve1,
  5. Gordon Guyatt4,
  6. Finn Gustafsson5,
  7. Heather Ross6,
  8. Ana Carolina Alba6
  1. 1 Ted Rogers Centre for Heart Research, Toronto General Hospital, Toronto, Ontario, Canada
  2. 2 Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3 Department of Cardiology, Rigshospitalet, Kobenhavn, Denmark
  4. 4 Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
  5. 5 Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
  6. 6 Cardiology, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
  1. Correspondence to Farid Foroutan, Ted Rogers Centre for Heart Research, Toronto General Hospital, Toronto, ON M5G 2N2, Canada; farid.foroutan{at}


Objective To date, long-term graft dysfunction, an important cause of death after heart transplantation, has been defined as a left ventricular ejection fraction (LVEF) of ≤40% or right atrial pressure (RAP) of ≥15 mm Hg. Empirical associations between measures of cardiac function and mortality post-transplant remain, however, unestablished.

Methods We conducted a retrospective two-centre cohort study of consecutive adults who underwent heart transplant between 2002 and 2017. We evaluated the association between LVEF and RAP and mortality, including rejection and cardiac allograft vasculopathy as additional time-dependent covariates using Cox proportional hazard models. We applied restricted cubic splines to both LVEF and RAP.

Results Of 590 eligible heart transplant recipients, of whom 72% were male with a mean age of 49 years, 410 received their transplant at Toronto General Hospital and 180 at Rigshospitalet. We observed a 5% absolute risk increase for 1-year mortality, from 11% to 16%, when the LVEF dropped to 53% (HR 1.71 for LVEF of 53% compared with 60%, 95% CI 1.36 to 2.14) or when the RAP increased to 12 mm Hg (HR 1.49 for RAP of 12 mm Hg compared with 5 mm Hg, 95% CI 1.04 to 2.13).

Conclusion In this study, we observed that small changes in graft function at any time post-transplant are associated with an increased mortality. Our results suggest that the current definition of graft dysfunction may underestimate patient risk of adverse outcomes.

  • heart Failure
  • heart transplantation
  • echocardiography
  • outcome assessment
  • health care

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors FF, ACA and HR conceived the study idea and objective. FF and GG conceived the study design and methods. FF, AM and LMSN conducted data collection. FF and C-PFS conducted the statistical analysis. All authors contributed to the writing and editing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.