Extracorporeal membrane oxygenation as a direct bridge to heart transplantation in adults

Fukuhara, Shinichi; Takeda, Koji; Kurlansky, Paul; Naka, Yoshifumi; Takayama, Hiroo

doi:10.1016/j.jtcvs.2017.10.152

Cited by 120 publications

(129 citation statements)

References 17 publications

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“…These findings support previous studies that have demonstrated the prognostic utility of MELD‐XI in predicting outcomes for patients supported with VA‐ECMO as a bridge to transplant 26,28 . Sern Lim 28 found remarkably similar results in a cohort of 26 patients undergoing VA‐ECMO as bridge to transplantation; 69% mortality for patients with a baseline MELD‐XI of 14 or greater compared to 31% for those with a baseline MELD‐XI less than 14.…”

Section: Resultssupporting

confidence: 87%

MELD‐XI is predictive of mortality in venoarterial extracorporeal membrane oxygenation

et al. 2020

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Background Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) is a life‐saving method of supporting critically ill patients. However, it is expensive and associated with high morbidity and mortality, making early predictive outcome modeling extremely valuable. The model for end‐stage liver disease‐excluding international normalized ratio (MELD‐XI) scoring system has been shown to have prognostic value in other critically ill patient populations. Materials and Methods A single‐center retrospective review was performed for all adult patients managed on VA‐ECMO from May 2011 to January 2018 (n = 247). Patients were included in the study if MELD‐XI scores could be calculated during the first 48 hours on ECMO (n = 187). Receiver operating characteristic curve analysis was performed for MELD‐XI in regard to in‐hospital mortality. Results Of the 187 patients, 74 (40%) patients had MELD‐XI less than 14 (low‐risk) and 113 (60%) had a MELD‐XI of 14 or greater (high‐risk). The cohorts did not differ significantly in terms of patient characteristics or indication for ECMO. The high‐risk MELD‐XI group had significantly greater mortality during index hospitalization compared to the low‐risk group (74% vs 39%; P < .0001). Quartile stratification demonstrated progressively worse prognosis associated with higher MELD‐XI scores; the fourth quartile showed a ninefold increased risk of mortality compared to the first quartile (P < .001). The AUC for predicting index hospitalization mortality was 0.69 (95% CI, 0.62‐0.77) with a Youden index (J) of 0.36 and optimized cutoff of 12.98. Conclusions These findings suggest that the MELD‐XI scoring system can be applied to the VA‐ECMO patient population early in their course of ECMO as a prognostic tool to aid in complex clinical decision making.

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Section: Resultssupporting

confidence: 87%

MELD‐XI is predictive of mortality in venoarterial extracorporeal membrane oxygenation

et al. 2020

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“…The combination of the recent prioritization of patients on TMCS and reports of ECMO BTT mortality exceeding 30% at 1-year follow-up has made Impella 5.0 an attractive device option for direct bridge to OHT. 1,3,7 Furthermore, bridging patients in refractory cardiogenic shock with Impella 5.0 provides excellent hemodynamic support with the potential for reversal of end-organ dysfunction while waitlisted for OHT. 11 The risk of device-failure and device-related complications with prolonged Impella 5.0 support is not uncommon and often necessitates either cardiac recovery or a bridge to a CF-LVAD or OHT.…”

Section: Discussionmentioning

confidence: 99%

“…The improvement in outcomes of continuous-flow left ventricular assist devices (CF-LVAD) over the last several years led many to question whether patients supported with CF-LVAD should be less prioritized on the heart transplant waiting list. [1][2][3] Indeed, patients with CF-LVADs have historically superior waitlist survival and rates of transplantation when compared to patients supported with temporary mechanical circulatory support (TMCS). 4,5 The surmounting evidence that CF-LVAD and TMCS outcomes were discrepant was addressed during the adoption of a new multi-tiered allocation policy in October 2018.…”

Section: Introductionmentioning

confidence: 99%

Direct bridging to cardiac transplantation with the surgically implanted Impella 5.0 device

Seese

Hickey

Keebler

et al. 2020

Clinical Transplantation

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This study evaluated outcomes of direct bridging to orthotopic heart transplantation (OHT) with the Impella 5.0 device. Adult recipients in the United Network for Organ Sharing registry bridged to OHT with the Impella 5.0 device between 2010 to 2018 were included. Outcomes included waitlist and post‐transplant survival. A total of 236 patients were wait‐listed with Impella 5.0 support, and 24% (n = 57) underwent bridge to OHT. Early and late post‐transplant survival was excellent at 96.5% at 30 day, 93.8% at 90‐day, and 90.3% at 1‐year follow‐up. Post‐transplant complications were infrequent, but the most common were renal failure requiring dialysis (8.8%, n = 5), cerebrovascular accidents (1.8%, n = 1), and pacemaker implant (1.8%, n = 1). The rate of waitlist removal for death or clinical deterioration was 20.0% (n = 47); however, the majority of patients were bridged to OHT (24%, n = 57) or durable continuous‐flow left ventricular assist device (37.0%, n = 87). The median time supported on the device, while waitlisted was 13 days (Interquartile range [IQR] 7, 20 days). The Impella 5.0 device can be used as a direct bridge to OHT with excellent survival and minimal post‐transplant morbidity. Overall, these data support the utilization of Impella 5.0 as a bridge to OHT in select patients with refractory cardiogenic shock.

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“…The combination of the recent prioritization of patients on TMCS and reports of ECMO bridge-to-transplantation (BTT) mortality exceeding 30% at 1-year follow-up has made surgically implanted T-LVADs with and without T-RVADs an attractive clinical option for BTT patients. 1,3,6 The risk of mortality and device-related complications in patients on prolonged T-LVADs is exceedingly high necessitating either cardiac recovery, durable CF-LVAD implantation or OHT to avoid mortality. 8,9 The current evidence describing the outcomes following a direct bridge from T-LVADs to OHT is limited to small cohorts that include a variety of TMCS devices.…”

Section: Discussionmentioning

confidence: 99%

“…The number of patients listed for an orthotopic heart transplant (OHT) has increased over the past decade due to the rising incidence of refractory heart failure as well as increased survival in patients supported with durable continuous-flow left ventricular assist devices (CF-LVADs). [1][2][3] Patients with CF-LVADs have superior waitlist survival and rates of transplantation when compared with patients supported with surgically implanted temporary left ventricular assist devices (T-LVAD), with and without temporary right ventricular assist devices (T-RVAD). 4,5 To create equitable access to donor organs for the highest mortality patients, the Organ Procurement and Transplantation Network in association with the United Network for Organ Sharing (UNOS) updated the cardiac transplant allocation system in October 2018.…”

Section: Introductionmentioning

confidence: 99%

Temporary left ventricular assist devices as a bridge to heart transplantation

et al. 2020

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Background To create equitable access to donor organs for the highest mortality patients, the cardiac transplant allocation system now prioritizes patients with surgically implanted temporary left ventricular assist devices (T‐LVADs). The outcomes following a direct bridge from a T‐LVAD to orthotopic heart transplant (OHT) are not well delineated. Aim This study investigates the T‐LVAD waitlist outcomes and compares the posttransplant outcomes in patients bridged to OHT with surgically implanted T‐LVADs to patients bridged with durable continuous‐flow left ventricular assist devices (CF‐LVADs). Methods Adults recorded in the United Network for Organ Sharing registry bridged to OHT with a durable CF‐LVAD and T‐LVADs, with or without temporary right ventricular assist devices (T‐RVADs), between 2010 and 2018 were included. Propensity matching and multivariable Cox regression were utilized to compare outcomes. Results Of 504 patients waitlisted with T‐LVADs, the majority were transplanted (50%), bridged to CF‐LVAD (17%), or recovered (9%). A total of 9047 recipients were bridged to OHT during the study period with 8875 CF‐LVADs and 172 T‐LVADs. Early survival in propensity‐matched T‐LVAD ± T‐RVAD patients was similar to CF‐LVAD ± T‐RVAD patients but reduced at a 1‐year follow‐up. This difference in survival at 1‐year follow‐up was attributable to significantly reduced survival in patients with combined T‐LVAD + T‐RVAD support when compared with CF‐LVAD, isolated T‐LVAD and combined CF‐LVAD + T‐RVAD support (80% vs 90% vs 90% vs 91%; P = .005). Conclusions This study demonstrates that most patients waitlisted with a T‐LVAD are successfully bridged to durable therapy or recover, and those bridged to OHT have acceptable posttransplant outcomes, particularly when T‐RVADs are not required.

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Extracorporeal membrane oxygenation as a direct bridge to heart transplantation in adults

Abstract: Bridge to transplant with ECMO was associated with increased early/mid-term mortality, especially in patients with a high MELD-XI score who demonstrated > 50% 3-year mortality. These findings may help to inform future organ allocation policies.

Cited by 120 publications

References 17 publications

MELD‐XI is predictive of mortality in venoarterial extracorporeal membrane oxygenation

MELD‐XI is predictive of mortality in venoarterial extracorporeal membrane oxygenation

Direct bridging to cardiac transplantation with the surgically implanted Impella 5.0 device

Temporary left ventricular assist devices as a bridge to heart transplantation

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