Extracorporeal Life Support to Left Ventricular Assist Device Bridge to Heart Transplant : A Strategy to Optimize Survival and Resource Utilization

Abstract

Background-The use of extracorporeal life support (extracorporeal membrane oxygenation [ECMO]) as a direct bridge to heart transplant in adult patients is associated with poor survival. Similarly, the use of an implantable left ventricular assist device (LVAD) to salvage patients with cardiac arrest, severe hemodynamic instability, and multiorgan failure results in poor outcome. The use of LVAD implant in patients who present with cardiogenic shock who have not been evaluated for transplantation or who have sustained a recent myocardial infarction also raises concerns. ECMO may provide reasonable short-term support to patients with severe hemodynamic instability, permit recovery of multiorgan injury, and allow time to complete a transplant evaluation before long-term circulatory support with an implantable LVAD is instituted. After acquisition of the HeartMate LVAD (Thermo Cardiosystems, Inc), we began using ECMO as a bridge to an implantable LVAD and, subsequently, to transplantation in selected high-risk patients. adult patients who presented with refractory cardiogenic shock (cardiac index Ͻ2.0 L ⅐ min Ϫ1 ⅐ m Ϫ2 , with systolic blood pressure Ͻ100 mm Hg and pulmonary capillary wedge pressure Ն24 mm Hg and dependent on Ն2 inotropes with or without intra-aortic balloon pump) were evaluated and accepted as candidates for mechanical assistance as a bridge to transplant. Of the 32 patients, 14 (group I) had a cardiac arrest or severe hemodynamic instability (systolic blood pressure Յ75 mm Hg) with evidence of multiorgan failure (defined as serum creatinine level Ͼ3 mg/dL or oliguria; international normalized ratio Ͼ1.5 or transaminases Ͼ5 times normal or total bilirubin Ͼ3 mg/dL; and needing mechanical ventilation). Group I patients were placed on ECMO support; 7 underwent subsequent LVAD implant and 1 was bridged directly to transplant. Six patients in group I survived to transplant hospitalization discharge. The remaining 18 patients (group II) underwent LVAD implant without ECMO support; 12 survived to transplant hospitalization discharge and 2 remained alive with ongoing LVAD support and awaited transplant. One-year actuarial survival from the initiation of circulatory support was 43% in group I and 75% in group II. One-year actuarial survival from the time of LVAD implant in group I, conditional on surviving ECMO, was 71% (PϭNS compared with group II). Conclusions-In appropriately selected high-risk patients, the rate of LVAD survival after initial ECMO support was not significantly different from the survival rate after LVAD support alone. An initial period of resuscitation with ECMO is an effective strategy to salvage patients with extreme hemodynamic instability and multiorgan injury. Use of LVAD resources is improved by avoiding LVAD implant in a very-high-risk cohort of patients who do not survive ECMO. (Circulation. 1999;100[suppl II]:II-206 -II-210.)

Impact of Preoperative Percutaneous Cardiopulmonary Support on Outcome Following Left Ventricular Assist Device Implantation

“…The incidence of right ventricular failure after LVAD implantation was higher in patients with preoperative PCPS, 5 and preoperative circulatory support was the most significant risk factor for mechanical right ventricular support after LVAD implantation. 14 In the present series, more patients with preoperative PCPS developed right ventricular failure, which required prolonged i.v.…”

“…4, 5 The impact of preoperative PCPS on LVAD support, however, remains inconclusive. McCarthy et al found that prior PCPS was a significant risk factor for death after LVAD implantation, 13 whereas Pagani et al reported that preoperative PCPS was not a risk factor for death after LVAD implantation.…”

Factors for Successful Weaning From a Percutaneous Cardiopulmonary Support System (PCPS) in Patients With Low Cardiac Output Syndrome After Cardiovascular Surgery

“…4) In this retrospective study, we analyzed data from patients who required PCPS to determine early predictive factors for successful weaning from PCPS in patients with low cardiac output syndrome after cardiovascular surgery.…”

Is there light at the end of the tunnel?—new perspectives in ECMO survival

“…The temporary support should guarantee the resuscitation and resolution of organ dysfunction before LVAD implant, as well as performance of an adequate transplant evaluation (55).…”