Extracorporeal life support in preoperative and postoperative heart transplant management

Abstract

Increased experience with extracorporeal life support (ECLS) as a mode of cardiac support has expanded its use to diverse patient populations including patients requiring a bridge to heart transplantation and patients requiring posttransplant support for primary graft dysfunction (PGD). The use of ECLS is associated with acceptable outcomes in well-selected patients. While outcomes with the use of extracorporeal membrane oxygenation (ECMO) as a bridge to heart transplant have been variable, several series have confirmed the safe use of ECLS to stabilize patients prior to left ventricular assist device (LVAD) implantation. These patients are then considered later, when in stable condition, for heart transplant.When ECLS is used prior to heart transplant, mortality is greatest during the first 6 months posttransplant.Patients who are alive 6 months after transplant appear to have similar survival rates as patients who were not supported with ECLS prior to transplant. ECLS support is a reliable therapeutic option for severe PGD and early graft failure after heart transplantation. In patients who require support for severe PGD, venoarterial-ECMO appears to result in better clinical outcomes than LVAD support. ECLS use for PGD after heart transplant continues to be the first line of support. Further studies are necessary to understand the optimal role of ECLS in heart transplantation.

Extracorporeal membrane oxygenation as treatment of graft failure after heart transplantation

“…Extracorporeal membrane oxygenation (ECMO) as treatment of graft failure after heart transplantation (HTx): a "simple" mechanical solution to a multifactorial problem HTx is a valuable option in eligible patients with end-stage heart failure, secondary to cardiomyopathy, failed palliation of congenital heart disease or acquired cardiac disease (1)(2)(3)(4). One of the most significant complications in the immediate post-operative period is early graft failure (EGF), with a mean incidence of 20-25% (1,(3)(4)(5). EGF can result from long ischemic time, increased donor age, inadequate myocardial preservation at time of procurement, increased pulmonary vascular resistances, hyperacute rejection, or poor adaptation of the graft to the recipient's hemodynamic environment (1,5).…”

“…EGF can result from long ischemic time, increased donor age, inadequate myocardial preservation at time of procurement, increased pulmonary vascular resistances, hyperacute rejection, or poor adaptation of the graft to the recipient's hemodynamic environment (1,5). EGF is a major risk factor for death and accounts for 40-50% of early mortality after HTx (4,6,7), with a 4.5-fold increased risk of mortality compared to HTx patients without EGF (15% vs. 60%) (5,7,8) and represents the most common cause of in-hospital mortality after HTx (3,5), with a negative impact on early and late outcomes (5). The absence of EGF is associated with better long-term survival (94% at 1 year and 81% at 5 years) compared to patients with severe EGF (survival: 36% at 1 year and 28% at 5 years) (7).…”

Heart re-transplantation in Eurotransplant

“…During the latest consensus conference on PGD after cardiac transplantation and confirmed by single centre experiences temporary ventricular assist devices and veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) can now be seen as established effective treatment options for severe PGD whose intervention can preclude emergency salvage re‐transplantation . In the majority of cases (75–87%), donor hearts recovered and patients could be weaned from ECMO support with acceptable survival (55–70%) . In the absence of randomized clinical trials, extracorporeal life support (ECLS) as bridge to recovery for severe PGD after heart transplant continues to be the first line of support with some recent evidence of improved outcomes as compared with short‐term VAD use .…”

A quantified description of the interactions between the native cardiovascular system and femoro‐femoral versus femoro‐axillary extracorporeal life support using descending thoracic aorta velocity time integral

“…Extracorporeal membrane oxygenation (ECMO) or life support (ECLS) is increasingly used to provide life‐saving cardiac or respiratory support for a variety of clinical conditions . Veno‐arterial (VA)‐ECLS has gained a place in the management of refractory cardiac failure of various etiologies, with or without respiratory failure, of cardiac arrest, as temporary circulatory support or as a bridge‐to‐decision‐making …”

“…[1][2][3] Veno-arterial (VA)-ECLS has gained a place in the management of refractory cardiac failure of various etiologies, with or without respiratory failure, of cardiac arrest, as temporary circulatory support or as a bridge-to-decision-making. [4][5][6][7] Despite its widespread use, many ECLS-related issues are still to be clarified. 8 There are 2 types of VA-ECLS determined by the arterial cannula insertion method: peripheral and central.…”