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

Abstract

Aims Primary graft dysfunction (PGD) is a feared complication after heart transplantation (HTX). HTX patients frequently receive veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) until graft recovery. Long‐term mortality of patients weaned from VA‐ECMO after HTX is comparable with non‐ECMO patients. However, impact on quality of life is unknown. This study investigated days alive and out of hospital (DAOH) as patient‐centred outcome in HTX patients at 1 year after surgery. Methods and results This retrospective single‐centre cohort study included patients who underwent HTX at the University Hospital Düsseldorf, Germany, from 2010 to 2020. Main exposure was VA‐ECMO due to PGD. VA‐ECMO and non‐VA‐ECMO patients were compared regarding the primary endpoint DAOH at 1 year after HTX. Subgroup analysis for patients weaned from VA‐ECMO was performed. In total, 144 patients were included into analysis; 1 year mortality was significantly lower in non‐ECMO patients [non‐ECMO 14.3% (14/98) vs. VA‐ECMO 34.8% (16/46), adjusted hazard ratio: 0.32, 95% confidence interval: 0.15–0.74; P = 0.002]. Mortality did not differ significantly between patients weaned from VA‐ECMO and non‐ECMO patients [non‐ECMO 14.3% (14/98) vs. VA‐ECMO (weaned) 18.9% (7/37), adjusted hazard ratio: 0.72, 95% confidence interval: 0.27–1.90; P = 0.48]. DAOH were significantly higher in non‐ECMO patients compared with VA‐ECMO patients and patients weaned from VA‐ECMO [non‐ECMO vs. VA‐ECMO: median 310 (inter‐quartile range 277–327) days vs. 243 (0–288) days; P < 0.0001; non‐ECMO vs. VA‐ECMO (weaned): 310 (277–327) days vs. 253 (208–299) days; P < 0.0001]. These results were still significant after multivariable adjustment with forced entry of predefined covariables. Conclusions Despite similar survival rates, VA‐ECMO due to PGD has a relevant life impact as defined by DAOH in the first year after HTX. As a more patient‐centred endpoint, DAOH may contribute to a more comprehensive assessment of outcome in HTX patients.

Impact of Cardiopulmonary Resuscitation of Donors on Days Alive and Out of Hospital after Orthotopic Heart Transplantation

“…The primary endpoint of this study was days alive and out of hospital (DAOH) at one year after HTX. The calculation of DAOH was performed in the same manner as reported previously [16,17]. Briefly, DAOH is equal to the sum of days in hospital for one patient, subtracted from 365 days.…”

“…However, from a patient point of view, there might be other important factors next to solely survive and it is unclear how donor CPR affects patient quality of life. Days alive and out of hospital (DAOH) has been suggested as an alternative endpoint to quantify life impact, as it captures mortality, re-hospitalizations, and quality of life to an extent [14][15][16][17]. In this study, we evaluated the impact of donor CPR on DAOH in patients undergoing HTX.…”

Validation of days alive and out of hospital as a new patient-centered outcome to quantify life impact after heart transplantation

“…DAOH at 1 year after HTX was the primary endpoint of this study. Calculation of DAOH was performed as previously described 8 , 10 . In brief, all days of hospitalization in the first year after HTX were summed up and subtracted from 365 days.…”

“…Accordingly, the following 19 predefined recipient-, donor- and transplant-related variables were included: (1) preoperative variables: recipient age, recipient sex, underlying disease, recipient diabetes, recipient estimated glomerular filtration rate (eGFR), recipient arterial hypertension, recipient body mass index (BMI), recipient pulmonary hypertension, recipient cytomegalovirus (CMV) status, previous cardiothoracic surgery, left ventricular assist device before HTX, donor age, donor sex, donor diabetes, sex mismatch between donor and recipient, total ischemic time; (2) postoperative: recipient renal replacement therapy (RRT), duration of mechanical ventilation, use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Data on influence of VA-ECMO therapy on DAOH has been published previously by our group 8 . The present study complements these data, as sample size was smaller in the previously published report.…”

“…Further advantages of DAOH are that it is easy to measure, readily available and it can be regarded as a composite of multiple clinically relevant outcomes including mortality, length and number of (re-)hospitalization and—indirectly—health care costs due to hospitalizations. A previous study showed that veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy due to primary graft dysfunction has critical life impact at 1-year after HTX measured by DAOH 8 . Interestingly, patients who could be successfully weaned from VA-ECMO showed lower DAOH as compared to patients without primary graft dysfunction whilst 1-year mortality did not differ between groups in this study.…”