Reduced left atrial compliance exacerbates primary graft dysfunction after lung transplantation.

Objective: Primary graft dysfunction (PGD) after lung transplantation (LTx) heralds significantly worse short- and long-term outcomes. The preoperative presence of recipient left ventricular diastolic dysfunction elevates postcapillary hydrostatic pressures and increases the risk for PGD. In this study, we investigated the role of the left atrial strain (LAS), a recently established sensitive marker of left atrial compliance, as a predictor of PGD.

Methods: Preoperative echocardiography of all patients who underwent bilateral LTx at a single center from 2014 to 2024 was analyzed for global myocardial deformation, including the standard phases of LAS reservoir, conduit, and pump as well as left ventricular global longitudinal strain. The presence of PGD grade 3 was defined as P:F <200 at 48 or 72 hours after the operation. Right heart catheterization, standard echocardiographic, and strain indices were subjected to univariable and multivariable analysis to predict PGD.

Results: In total, 132 patients were analyzed, from whom 35 (26.5%) developed PGD. There were no differences in traditional echocardiographic left ventricular diastolic dysfunction biomarkers, including Doppler and tissue Doppler indices, between the PGD (+) and PGD (-) groups. Preoperative right heart catheterization revealed increased mean pulmonary arterial pressure (36 vs 26 mm Hg, P = .003) and median pulmonary vascular resistance (7.8 vs 4.6, P = .001) in the PGD group. Reservoir LAS was reduced in PGD (22.7 ± 7.7 vs 31.5 ± 10.7%, P < .001), followed by reduced conduit LAS (-11.4 ± 6.6 vs -16.0 ± 8.2%, P = .002) and reduced LV GLS (-13.9 ± 3.6 vs -15.8 ± 3.7%, P = .014). In final multivariable model, conduit LAS was independently associated with a greater risk of PGD (odds ratio, 0.88; 95% confidence interval, 0.81-0.95; P = .002) along with greater pulmonary vascular resistance index (odds ratio, 1.13; 95% confidence interval, 1.05-1.25; P = .003). The final model yielded a c-statistic of 0.82, specificity of 93.8%, sensitivity of 40.0%, positive predictive value of 80.8%, and negative predictive value of 70.6%.

Conclusions: Patients with decreased preoperative left atrial compliance assessed by LAS who undergo LTx have a greater risk of developing PGD in the setting of normal LV systolic and diastolic function. Given the increasing use of strain indices, LAS should be considered a risk factor for PGD in prospective studies.