{
  "abstract": "BACKGROUND Risk models from high-income transplant programmes may not generalise to resource-constrained settings with different recipient acuity, donor characteristics and access to mechanical circulatory support. We developed RIGHT-HTx, a parsimonious framework integrating clinical and physiological vulnerabilities, and evaluated its prognostic performance in a subsequent same-centre cohort. METHODS This retrospective single-centre study included 436 consecutive adult heart transplant recipients (2012-2026). Of 357 development recipients, 341 (95.5%) were score-evaluable. RIGHT-HTx incorporated three vulnerability domains: clinical acuity (INTERMACS 1-2), graded renal dysfunction (eGFR 30-59 or <30 mL/min/1.73 m2) and haemodynamic-donor mismatch (TPG >12 mmHg combined with donor-to-recipient weight ratio <1.0). A seven-point Cox-derived score underwent internal validation using 1,000 bootstrap resamples and was applied unchanged to 79 subsequent recipients. Low-, intermediate- and high-risk categories represented zero, one and 2 affected domains, respectively. RESULTS Among development recipients, 75/341 (22.0%) died within one year. Mortality increased across low-, intermediate- and high-risk categories (8.1%, 20.3% and 55.6%; log-rank P<0.001). Elevated TPG was not significantly associated with mortality individually, whereas its combination with donor undersizing was independently associated with mortality (adjusted HR 2.87, 95% CI 1.53-5.40; P=0.001). The full model improved discrimination beyond renal dysfunction alone (optimism-corrected C-index 0.067), and the simplified score achieved an optimism-corrected C-index of 0.732. The temporal cohort more often had 1 affected domain (75.9% versus 60.4%; P=0.010). Discrimination was comparable (C-index 0.738, 95% CI 0.643-0.833), although observed Kaplan-Meier one-year mortality exceeded original predictions (35.4% versus 25.4%; calibration slope 0.929). In pooled analyses (n=420), mortality increased from 8.4% (13/154) with no affected domain to 57.3% (47/82) with two or more. CONCLUSIONS RIGHT-HTx identifies cumulative multidomain vulnerability associated with early mortality after heart transplantation. Temporal discrimination was comparable, but absolute-risk calibration differed. The framework may support risk recognition and mitigation, not transplant eligibility or allocation; independent multicentre validation is required before clinical implementation.",
  "abstract_shown": true,
  "affiliations": [
    "Institute of Heart and Lung Transplant & Mechanical Circulatory Support, MGM Healthcare"
  ],
  "article_type": "PUBLISHAHEADOFPRINT",
  "arxiv": null,
  "author_total": 16,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "K. R. Balakrishnan"
    },
    {
      "name": "S. R. Kemundel Genny"
    },
    {
      "name": "M. Tungatru"
    },
    {
      "name": "N. Davidson"
    },
    {
      "name": "A. Sahayaraj"
    },
    {
      "name": "A. Aravind"
    },
    {
      "name": "S. Vanga"
    },
    {
      "name": "N. Singh"
    },
    {
      "name": "N. Nallamuthu"
    },
    {
      "name": "A. Jegdish"
    },
    {
      "name": "K. Krithika"
    },
    {
      "name": "R. K. Ratnagiri"
    },
    {
      "name": "R. Chandrasekaran"
    },
    {
      "name": "R. K. RAMASWAMY"
    },
    {
      "name": "V. Manikala"
    },
    {
      "name": "A. Kumar"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/4sqwj4ryf3fpp.bib",
  "cited_by": 0,
  "doi": "10.64898/2026.11.03.26367231",
  "fulltext_url": "https://www.medrxiv.org/content/10.64898/2026.11.03.26367231v1.full",
  "id": "4sqwj4ryf3fpp",
  "issns": [],
  "landing_url": "https://www.medrxiv.org/content/10.64898/2026.11.03.26367231v1",
  "language": null,
  "licence": "CC-BY-NC-ND",
  "licence_label": "CC BY-NC-ND",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by-nc-nd/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "medrxiv",
      "cardiovascular medicine"
    ]
  ],
  "openalex": null,
  "pdf_url": "https://www.medrxiv.org/content/10.64898/2026.11.03.26367231v1.full.pdf",
  "pmcid": null,
  "pmid": null,
  "published": "2026-11-03",
  "publisher": null,
  "ris": "https://research.draconitic.com/paper/4sqwj4ryf3fpp.ris",
  "sources": [
    {
      "first_seen": "2026-11-06T12:20:48Z",
      "native_id": "10.64898/2026.11.03.26367231",
      "source": "medrxiv",
      "url": "https://www.medrxiv.org/content/10.64898/2026.11.03.26367231v1"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "medrxiv:cardiovascular medicine",
      "subfield": "cardiovascular"
    }
  ],
  "title": "Cumulative Multidomain Vulnerability and Early Mortality After Heart Transplantation: Development and Temporal Evaluation of the RIGHT-HTx Framework",
  "title_text": "Cumulative Multidomain Vulnerability and Early Mortality After Heart Transplantation: Development and Temporal Evaluation of the RIGHT-HTx Framework",
  "type": "preprint",
  "updated_at": "2026-11-07T00:20:54Z",
  "url": "https://research.draconitic.com/paper/4sqwj4ryf3fpp",
  "venue": "medRxiv",
  "versions": []
}