Extracorporeal membrane oxygenation bridge to heart transplant: Trends following the allocation change

Hess, Nicholas R.; Hickey, Gavin; Sultan, Ibrahim; Kilic, Arman

doi:10.1111/jocs.15118

Cited by 26 publications

(35 citation statements)

References 14 publications

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“…Our findings expand on work by Kilic and colleagues, who found improved waitlist outcomes but similar post-transplant mortality for ECMO patients following the rule change [5].…”

Section: Plos Onesupporting

confidence: 86%

“…Conversely, temporary MCS (tMCS) devices such as ECMO and IABP are increasingly used as bridge to transplantation [3,4]. While such changes in MCS use under the new system have been previously described [4][5][6][7][8], little is known regarding the characteristics and outcomes of the large influx of patients now being bridged with ECMO in the new allocation scheme. The present study characterized changes in waitlist and post-transplant outcomes of ECMO patients being bridged to transplantation following the 2018 OPTN policy change.…”

Section: Introductionmentioning

confidence: 99%

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Outcomes of extracorporeal membrane oxygenation following the 2018 adult heart allocation policy

et al. 2022

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Background The purpose of the study was to characterize changes in waitlist and post-transplant outcomes of extracorporeal membrane oxygenation (ECMO) patients bridged to heart transplantation under the 2018 adult heart allocation policy. Methods All adult patients listed for isolated heart transplantation from August 2016 to December 2020 were identified using the United Network for Organ Sharing database. Patients were stratified into Eras (Era 1 and Era 2) centered around the policy change on October 18, 2018. Competing risk regression was used to evaluate waitlist death or deterioration across Eras. Cox proportional hazards models were used to determine associations between use of ECMO and 1-year post-transplant mortality within each Era. Results Of 8,902 heart transplants included in analysis, 339 (3.8%) were bridged with ECMO (Era 2: 6.1% vs Era 1: 1.2%, P<0.001). Patients bridged with ECMO in Era 2 were less frequently female (26.0% vs 42.0%, P = 0.02) and experienced shorter waitlist times (5 vs 11 days, P<0.001) along with a lower likelihood of waitlist death or deterioration (subdistribution hazard ratio, 0.45, 95% confidence interval, CI, 0.30–0.68, P<0.001) compared to those in Era 1. Use of ECMO was associated with increased post-transplant mortality at 1-year compared to all other transplants in Era 1 (hazard ratio 3.78, 95% CI 1.88–7.61, P < 0.001) but not Era 2. Conclusions Patients bridged with ECMO in Era 2 experience improved waitlist and post-transplant outcomes compared to Era 1, giving credence to the increased use of ECMO under the new allocation policy.

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“…Our findings expand on work by Kilic and colleagues, who found improved waitlist outcomes but similar post-transplant mortality for ECMO patients following the rule change [5].…”

Section: Plos Onesupporting

confidence: 86%

Section: Introductionmentioning

confidence: 99%

Outcomes of extracorporeal membrane oxygenation following the 2018 adult heart allocation policy

et al. 2022

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“…A similar study was performed by Hess et al who demonstrated a higher likelihood of HT in patients supported with ECMO in the new allocation system and a marked reduction in median waitlist time from 47 to four days. The authors established comparable one-year survival rates in the new and old system (new 79.8% vs. old 90.3%; p = 0.3917), with equivalent rates of stroke and one-year acute rejection, although postoperative renal failure was significantly higher in the new policy group [ 22 ]. Several other studies reported significant improvement in post-transplant survival, a lower hazard of post-transplant mortality, a lower rate of waitlist mortality, and an up to 50% reduced waitlist time after implementation of the new system (from 11 or 10 days vs. five days) [ 23 , 24 ], as well.…”

Section: Ecmo As a Bridge To Ht Strategy In Different Allocation Syst...mentioning

confidence: 99%

Veno-Arterial Extracorporeal Membrane Oxygenation as a Bridge to Heart Transplant—Change of Paradigm

Šipuš

Krželj

Đurić

et al. 2022

JCM

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Despite advances in medical therapy and mechanical circulatory support (MCS), heart transplant (HT) remains the gold standard therapy for end-stage heart failure. Patients in cardiogenic shock require prompt intervention to reverse hypoperfusion and end-organ damage. When medical therapy becomes insufficient, MCS should be considered. Historically, it has been reported that critically ill patients bridged with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) directly to HT have worse outcomes. However, when the heart allocation system gives the highest priority to patients on VA-ECMO support, those patients have a higher incidence of HT and a lower incidence of death or removal from the transplant list. Moreover, patients with a short waiting time on VA-ECMO have a similar hazard of mortality to non-ECMO patients. According to the reported data, bridging with VA-ECMO directly to HT may be a solution in the selection of critically ill patients when the anticipated waiting list time is short. However, when a prolonged waiting time is expected, more durable MCS should be considered. Regardless of the favorable results of the direct bridging to HT with ECMO in selected patients, the superiority of this strategy compared to the bridge-to-bridge strategy (ECMO to durable MCS) has not been established and further studies are mandatory in order to clarify this issue.

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“…The reasoning for this is unclear given the limitations of the UNOS database. While donor organ allocation status changes in 2018 have affected strategies of bridging patients to transplant with both durable and temporary mechanical circulatory support, the TAH continues to have Status 2 allocation in the new scheme so this should not have necessarily decreased transplant offers 10,11. What the change in allocation strategy did affect as demonstrated by our study was the waitlist time for TAH BTT therapy, which was significantly shorter in the TAH population after 2018.…”

mentioning

confidence: 73%

Trends and outcomes following total artificial heart as bridge to transplant from the UNOS database

Coyan

Huckaby

Díaz-Castrillón

et al. 2022

Journal of Cardiac Surgery

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Introduction Bridge to transplantation (BTT) with a SynCardia Total Artificial Heart (TAH) has been gaining momentum as a therapy for patients with biventricular heart failure. Recent transplant waitlist and posttransplant outcomes with this strategy have not been comprehensively characterized. We reviewed the United Network for Organ Sharing (UNOS) database to examine BTT outcomes for the TAH system since approval. Methods Adult patients listed for heart transplantation in the UNOS system between 2004 and 2020 who underwent BTT therapy with a TAH were included in the study. Trends in utilization of TAH compared with other durable mechanical support strategies were examined. The primary outcome was 1‐year survival following heart transplantation following BTT with TAH. Secondary outcomes included waitlist deterioration and risk factors for waitlist or posttransplant mortality. Results During the study 433 total patients underwent TAH implant as BTT therapy; 236 (54.4%) were listed with the TAH, while the remaining patients were upgraded to TAH support while on the waitlist. Waitlist mortality was 7.4%, with 375 patients (86.6%) ultimately being transplanted. Age, cerebrovascular disease, functional status, and ventilator dependence were risk factors for waitlist mortality. One‐year survival following successful BTT was 80%. Risk factors for mortality following BTT included age, body mass index, and underlying diagnosis. Conclusions Patients undergoing BTT with TAH demonstrate acceptable waitlist survival and good 1‐year survival. While utilization initially increased as a BTT therapy, there has been a plateau in relative utilization. Individual patient and transplantation center factors deserve further investigation to determine the ideal population for this therapy.

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Extracorporeal membrane oxygenation bridge to heart transplant: Trends following the allocation change

Cited by 26 publications

References 14 publications

Outcomes of extracorporeal membrane oxygenation following the 2018 adult heart allocation policy

Outcomes of extracorporeal membrane oxygenation following the 2018 adult heart allocation policy

Veno-Arterial Extracorporeal Membrane Oxygenation as a Bridge to Heart Transplant—Change of Paradigm

Trends and outcomes following total artificial heart as bridge to transplant from the UNOS database

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