Elevated oxygen extraction during heart transplantation is associated with increased morbidity and mortality: Implications for goal-directed perfusion
Abstract
Background: Goal-directed perfusion (GDP) during cardiopulmonary bypass (CPB) commonly targets indexed oxygen delivery (DO2i), yet fixed delivery thresholds may ignore patient-specific metabolic demand. The oxygen extraction ratio (O2ER) integrates delivery and consumption and may better reflect supply-demand balance during heart transplantation. We evaluated whether intra-CPB O2ER burden is associated with adverse outcomes after adult heart transplantation and whether O2ER provides incremental prognostic value beyond DO2i.
Methods: We retrospectively analyzed adult heart transplantations performed at a single center between November 2021 and June 2025. Minute-level CPB data were extracted. O2ER was the primary exposure, and the primary outcome was a composite morbidity-mortality (M-M) endpoint (severe primary graft dysfunction [PGD], ventilation for >72 hours, intensive care unit length of stay >15 days, renal replacement therapy, or 90-day mortality). Generalized propensity score-weighted logistic regression modeled associations adjusting for prespecified donor/recipient/procedural covariates. Comparative models assessed O2ER versus DO2i. A post hoc analysis quantified pre- and post-reperfusion O2ER area under the receiver operating characteristic curve (AUC) to localize phase-specific risk.
Results: Among 381 heart transplant recipients, 40 (10.5%) experienced M-M. O2ER trajectories separated between the M-M and non-M-M groups during the mid-procedure window (∼35-100…
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