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Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after heart transplantation (HTx). We retrospectively analyzed 830 consecutive HTx performed between 1984 and 2021. After excluding patients <18 years and those with missing data, 667 adult recipients remained. ISHLT PGD criteria were applied and perioperative variables and outcomes were reviewed. PGD occurred in 70 patients (10.5%), including 41 (6.1%) with left ventricular PGD and 29 (4.3%) with right ventricular PGD. Most LV-PGD cases were severe (88%). Patients with PGD were younger and more frequently had pretransplant dialysis, ventricular assist device support, or prior cardiac surgery. No donor-related factors were associated with PGD. Recipient-related factors and longer cardiopulmonary bypass time were associated with increased risk. PGD was associated with prolonged mechanical ventilation and ICU stay, and increased need for mechanical circulatory support, dialysis, reoperation, and treatment for sepsis. Mortality or re-transplantation was significantly higher in PGD patients at 30 days (45% vs. 3%) and 1 year (51% vs. 8%; HR 6.89, 95% CI 4.01-11.83, p < 0.0001).