Role of Intra‐Aortic Balloon Pump and Extracorporeal Membrane Oxygenation in Early Graft Failure After Cardiac Transplantation

Abstract

Early graft failure (EGF) is a major risk factor for death after heart transplantation (Htx). We investigated the predictive risk factors for moderate-to-severe EGF requiring an intra-aortic balloon pump (IABP) or extracorporeal membrane oxygenation (ECMO) circulatory support as treatment after Htx. Between January 2000 and December 2014, 412 consecutive adult patients underwent isolated Htx at our institution. Moderate and severe EGF were defined as the need for IABP and ECMO support, respectively, within 24 h after Htx. All available recipient and donor variables were analyzed to assess the risk of EGF occurrence. Overall, moderate-to-severe EGF occurred in 46 (11.1%) patients. Twenty-nine (63.04%) patients required peripheral or central ECMO support in the treatment of severe EGF and 17 (36.9%) patients required IABP support for the treatment of moderate EGF. The predictive risk factors for moderate-to-severe EGF in recipients, as assessed by logistic regression analysis, were a preoperative transpulmonary gradient > 12 mm Hg (odds ratio [OR] 5.2; P = 0.023), a preoperative inotropic score > 10 (OR 8.5; P = 0.0001), and preoperative ECMO support (OR 4.2; P = 0.012). For donors, the predictive risk factor was a donor score ≥ 17 (OR 8.3; P = 0.006). The absence of EGF was correlated with improved long-term survival: 94% at 1 year and 81% at 5 years without EGF versus 76% and 36% at 1 year (P < 0.001), and 70% and 28% at 5 years (P < 0.001) with EGF requiring IABP and ECMO support, respectively. In-hospital weaned and survived patients after IABP or ECMO treatment for moderate-to-severe EGF had a similar 5-year conditional survival rate as transplant patients who had not suffered EGF: 88% without EGF versus 84% with EGF treated with mechanical circulatory support devices (P = 0.08). The occurrence of EGF is a multifactorial deleterious event that depends on donor and recipient profiles. IABP and ECMO support are reliable treatment strategies, depending on the grade of EGF. Furthermore, surviving patients treated with IABP or ECMO have the same long-term conditional survival rate as patients who have not suffered EGF.

Extracorporeal membrane oxygenation as treatment of graft failure after heart transplantation

“…Long-term survival of ECMO survivors after EGF is excellent and comparable to non-ECMO patients, as survival rates among ECMO survivors is >90% at 3 years and >80% after a mean follow-up of 8 years (1,5). In another study, inhospital weaned and survived patients after IABP and ECMO treatment for moderate-to-severe EGF had a similar five-year conditional survival rate compared to transplant patients who had not suffered from EGF (88% without EGF versus 84% with EGF treated with TMCS devices) (7). Graft function appears to be not influenced by the use of ECMO, as shown by shortening fraction, ejection fraction and cardiac index (1,14).…”

“…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).…”

“…According to the last ISHLT consensus statement (18), EGF is classified as primary when the triggering factor is unknown and secondary when the cause can be determined, such as hyperacute rejection, pulmonary hypertension or surgical complication. The diagnosis of EGF should be made within 24 hours after HTx procedure and EGF is graded as mild, moderate or severe based on specified criteria (7,18), such as ejection fraction, cardiac index, pulmonary capillary wedge pressure, mean arterial pressure, inotropic score and intra-aortic balloon pump (IABP) use. The etiology of EGF after HTx is multifactorial and involves donor-recipient mismatching, inadequate donor heart preservation, use of marginal donor hearts and ABOincompatible HTx (3).…”

Extracorporeal life support for primary graft dysfunction after heart transplantation

“…Finally the introduction of a grading system of PGD severity could guide the subsequent decision-making algorithm [3]. Medical management seems useful in mild or moderate PGD while extracorporeal life support (ECLS) could be suggested as a therapeutic option for those severe cases of PGD that are refractory to maximal conventional treatment including inotropes, vasodilators and nitric oxide [4][5][6][7][8][9][10][11][12][13][14][15].…”

Heart re-transplantation in Eurotransplant

“…Until recently the only therapeutic option for PGD was a re‐HTX. 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%) .…”