Extracorporeal Life Support Bridge to Ventricular Assist Device: The Double Bridge Strategy

Abstract

In patients requiring left ventricular assist device (LVAD) support, it can be difficult to ascertain suitability for long-term mechanical support with LVAD and eventual transplantation. LVAD implantation in a shocked patient is associated with increased morbidity and mortality. Interest is growing in the utilization of extracorporeal life support (ECLS) as a bridge-to-bridge support for these critically unwell patients. Here, we reviewed our experience with ECLS double bridging. We hypothesized that ECLS double bridging would stabilize end-organ dysfunction and reduce ventricular assist device (VAD) implant perioperative mortality. We conducted a retrospective review of prospectively collected data for 58 consecutive patients implanted with a continuous-flow LVAD between January 2010 and December 2013 at The Alfred Hospital, Melbourne, Victoria, Australia. Twenty-three patients required ECLS support pre-LVAD while 35 patients underwent LVAD implantation without an ECLS bridge. Preoperative morbidity in the ECLS bridge group was reflected by increased postoperative intensive care duration, blood loss, blood product use, and postoperative renal failure, but without negative impact upon survival when compared with the no ECLS group. ECLS stabilization improved end-organ function pre-VAD implant with significant improvements in hepatic and renal dysfunction. This series demonstrates that the use of ECLS bridge to VAD stabilizes end-organ dysfunction and reduces VAD implant perioperative mortality from that traditionally reported in these "crash and burn" patients.

Prolonged mechanical ventilation after left ventricular assist device implantation: risk factors and clinical implications

“…A significant proportion of patients were on critical or rapidly declining clinical state (overall 59% in INTERMACS Level 1-3) and non-eligible for bridging therapies. [17][18][19] As expected, the duration of ICU and hospital stay exceeded those of patients with uncomplicated weaning. 12,13 Destination therapy is repeatedly shown to be an independent predictor of death, and this may have led to an increase in the reported PMV rates and mortality.…”

Extracorporeal life support in preoperative and postoperative heart transplant management

“…Consideration should be given to transitioning potential transplantation candidates to VAD support (bridge-to-bridge) if myocardial recovery does not occur within 7-14 days. A recent retrospective review of 58 consecutive patients who were implanted with a continuous-flow, axial LVAD found no difference in survival between patients who were bridged to durable mechanical circulatory support with ECLS and those who underwent durable device implantation without ECLS bridging (8). The authors observed significant improvements in hepatic and renal function and concluded that ECLS stabilization improved end-organ function prior to durable device implantation and reduced perioperative mortality during durable device implantation.…”

“…The use of ECLS and other short-term support devices per se has been described as a risk factor for mortality when used directly prior to transplant (7), and for this reason, ECLS has been mostly used as a double bridge or bridge-to-bridge (bridge to LVAD) to stabilize patients before LVAD implantation when considering heart transplant in a staged fashion only in patients who regain an acceptable clinical condition after support (8,9). The primary approach in the United States has been to favor the use of a durable ventricular assist device (VAD) as a bridge to heart transplant while reserving the use of short-term mechanical circulatory support, including ECMO, mostly as a double-bridge to heart transplant (8-10).…”

“…Since the first report by Pagani and colleagues of the use of ECMO as a "bridge to bridge" (11), several different series have confirmed the safe use of ECMO as a mechanism to stabilize patients prior to a durable LVAD implant who are then considered later, when in stable condition, for heart transplant (8)(9)(10). Survival with this double-bridge strategy has varied according to the patients selected, ranging from 30-80% survival after LVAD placement.…”

“…Tran and colleagues at UCLA reported 45% survival in patients supported on ECMO prior to different VAD options (12). Shah and colleagues (9) observed 1-year survival of 57%, and more recently Marasco observed 1-to 2-year survival of 75% in patients supported on VA-ECMO for CS (8). This was similar to survival in patients in whom an LVAD was placed directly with no ECMO support, suggesting that the use of ECLS as a bridge to VAD stabilizes end-organ dysfunction and reduces perioperative mortality after VAD implantation as compared with that traditionally reported in these "crash and burn" patients.…”