Extracorporeal membrane oxygenation as treatment of graft failure after heart transplantation

Abstract

Heart transplantation (HTx) is a valuable option in eligible patients with end-stage heart failure. The most significant complication in the immediate post-operative period is early graft failure (EGF), with a mean incidence of 20-25%. EGF is a major risk factor for death and accounts for 40-50% of early mortality after HTx. Despite the use of inotropes, EGF may persist and require temporary mechanical circulatory support. Extracorporeal membrane oxygenation (ECMO) has been investigated over the years and has proved to be a reliable strategy in patients with EGF after HTx. This study aims to review the contemporary literature on this topic. Considering short-term outcomes, 45-80% of patients were discharged alive from hospital. Duration of support is variable, with a mean duration of 4-8 days. Cannulation strategy and device selection have no differences with respect to short-term outcomes. The main causes of death are multi-organ failure, bleeding, heart failure, stroke and sepsis. Considering long-term outcomes, ECMO survivors appear to have similar survival rates to HTx patients who did not experience EGF. Also, ECMO-treated EGF, among survivors, has no detrimental effect for graft function. In conclusion, ECMO is a reliable therapeutic option to support patients with severe graft failure after HTx, providing adequate support with either central or peripheral arteriovenous cannulation. Further studies will be needed to establish the correct threshold for ECMO support and to provide long-term results.

Veno-Arterial Extracorporeal Membrane Oxygenation for Patients Undergoing Heart Transplantation: A 7-Year Experience

“…In this study, the successful weaning rate and mortality following VA-ECMO were 66 and 55%, respectively, which are comparable to those published by Alessandro et al (weaning: 60%, survival: 46%) (20). We believe that the main causes of this higher incidence rate and mortality may be associated with marginal donors, basic patient conditions, surgical strategies, longer cold ischemia duration, and indication for VA-ECMO despite its likelihood to be multifactorial (4,5,22). The timing of VA-ECMO implantation is an important factor influencing patient outcomes.…”

Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock

“…Limited data has shown a benefit for VA-ECMO use in selected patients ( 6 , 7 , 156 ) ( Table 2 ); (II) Primary graft dysfunction following orthotopic heart transplantation . Several studies have shown significantly improved outcomes when VA-ECMO is initiated early in this setting ( 11 , 20 , 157 , 158 ) ( Table 2 ); (III) Obstructive shock . Large intracardiac mass lesions, most commonly metastases, may limit blood flow across the cardiac valves.…”

Life impact of VA‐ECMO due to primary graft dysfunction in patients after orthotopic heart transplantation

“…Orthotopic heart transplantation (HTX) is the causal therapy for patients with end‐stage heart failure 1,2 . After HTX, primary graft dysfunction (PGD) is a feared complication occurring in up to 30% and strongly affecting survival chances of patients 3 . Therefore, these patients frequently receive extracorporeal mechanical support by veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) devices 4,5 .…”