Extracorporeal life support to left ventricular assist device bridge to heart transplant. A strategy to optimize survival and resource utilization

• Published in: Circulation (New York, N.Y.) N.Y.), 1999-11, Vol.100 (19), p.II206-II210
• Main Authors: PAGANI, F. D, LYNCH, W, AARONSON, K. D, SWANIKER, F, DYKE, D. B, BARTLETT, R, KOELLING, T, MOSCUCCI, M, DEEB, G. M, BOLLING, S, MONAGHAN, H
• Format: Article
• Language: English
• Subjects: Adult; Aged; Biological and medical sciences; Extracorporeal Membrane Oxygenation - instrumentation; Extracorporeal Membrane Oxygenation - methods; Female; Heart Transplantation - instrumentation; Heart Transplantation - mortality; Heart-Assist Devices; Humans; Male; Medical sciences; Middle Aged; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Survival Analysis
• ISSN: 0009-7322; 1524-4539
• DOI: 10.1161/01.cir.100.suppl_2.ii-206

The use of extracorporeal life support (extracorporeal membrane oxygenation [ECMO]) as a direct bridge to heart transplant in adult patients is associated with poor survival. Similarly, the use of an implantable left ventricular assist device (LVAD) to salvage patients with cardiac arrest, severe hemodynamic instability, and multiorgan failure results in poor outcome. The use of LVAD implant in patients who present with cardiogenic shock who have not been evaluated for transplantation or who have sustained a recent myocardial infarction also raises concerns. ECMO may provide reasonable short-term support to patients with severe hemodynamic instability, permit recovery of multiorgan injury, and allow time to complete a transplant evaluation before long-term circulatory support with an implantable LVAD is instituted. After acquisition of the HeartMate LVAD (Thermo Cardiosystems, Inc), we began using ECMO as a bridge to an implantable LVAD and, subsequently, to transplantation in selected high-risk patients. From October 1, 1996, through September 30, 1998, 32 adult patients who presented with refractory cardiogenic shock (cardiac index /=2 inotropes with or without intra-aortic balloon pump) were evaluated and accepted as candidates for mechanical assistance as a bridge to transplant. Of the 32 patients, 14 (group I) had a cardiac arrest or severe hemodynamic instability (systolic blood pressure 3 mg/dL or oliguria; international normalized ratio >1.5 or transaminases >5 times normal or total bilirubin >3 mg/dL; and needing mechanical ventilation). Group I patients were placed on ECMO support; 7 underwent subsequent LVAD implant and 1 was bridged directly to transplant. Six patients in group I survived to transplant hospitalization discharge. The remaining 18 patients (group II) underwent LVAD implant without ECMO support; 12 survived to transplant hospitalization discharge and 2 remained alive with ongoing LVAD support and awaited transplant. One-year actuarial survival from the initiation of circulatory support was 43% in group I and 75% in group II. One-year actuarial survival from the time of LVAD implant in group I, conditional on surviving ECMO, was 71% (P=NS compared with group II). In appropriately selected high-risk patients, the rate