Determinants of long-term outcomes in orthotopic heart transplantation: experience from the largest Ukrainian cohort

Background. Despite advances in surgical technique and immunosuppression, early- and late-onset cardiac complications remain the main limitation to long-term survival after orthotopic heart transplantation (OHT). Locally derived data are especially relevant for Ukraine, where the donor pool is older and metabolic disorders are more prevalent than the International Society for Heart and Lung Transplantation averages. Objective: to determine the frequency of key cardiac complications after OHT in the largest Ukrainian cohort and to establish independent predictors of each of them, paying special attention to the role of metabolic syndrome (MetS) and diabetes mellitus (DM). Materials and methods. We retrospectively analysed 112 adult recipients who underwent isolated OHT between 2019 and 2025 at a single centre. Four endpoints were assessed: primary graft dysfunction (PGD), acute rejection, cardiac allograft vasculopathy (CAV) and clinically significant arrhythmias. Descriptive statistics, univariate tests (, Fisher; t-test or Mann-Whitney) and four separate forced-entry logistic-regression models were applied. Model fit was checked with the Hosmer-Lemeshow test, discrimination with ROC AUC. Results. Median follow-up was 3.7 years (interquartile range 2.1–4.9). Overall incidence: PGD — 33 %, acute rejection — 38 %, CAV — 28 %, arrhythmias — 18 %. PGD: independent predictors: ischaemic time > 240 min (adjusted odds ratio 5.22; 95% confidence interval 1.75–15.5), systolic pulmonary artery pressure (PAPsys) > 50 mmHg (4.81; 1.84–12.5), donor vasoactive-inotropic score (VIS) > 25 (2.50; 0.92–6.81), donor age > 50 years (2.67; 1.02–6.97) and recipient DM (2.27; 0.56–9.25). Acute rejection: recipient age < 30 years (4.40; 1.64–11.8), female sex (3.52; 1.09–11.3), chronic kidney disease (3.49; 1.13–10.7), PAPsys > 50 mmHg (2.24; 0.95–5.30) and DM (2.02; 0.55–7.44). Arrhythmias: donor VIS > 25 (7.33; 2.42–22.2), pre-operative extracorporeal membrane oxygenation/intra-aortic balloon pump (3.59; 1.08–11.9), donor age > 50 years (2.17; 0.71–6.68) and ischaemic time > 240 min (2.07; 0.58–7.34). CAV: prior rejection episodes (13.9; 4.44–43.6), MetS (4.03; 1.21–13.4), donor age > 50 years (3.98; 1.07–14.7), donor VIS > 25 (2.74; 0.78–9.60), DM (4.43; 0.74–26.5) and chronic kidney disease (2.42; 0.57–10.3). Conclusions. Early mechanical complications are primarily driven by donor organ quality and implantation haemodynamics, whereas immune-mediated rejection and CAV reflect a synergy between immunological triggers and recipient metabolic status. MetS and DM act as universal amplifiers of adverse events. Rigo-rous donor selection (younger age, low VIS, ischaemic time < 180 min), aggressive management of pulmonary hypertension, and early metabolic optimisation (HbA1c < 6.5 %, statins, mo-dern antidiabetic agents) could substantially reduce critical cardiac complications and improve long-term graft survival in the Ukrainian transplant population.