Successful Use of Veno-Arterial Extracorporeal Membrane Oxygenation as a Bridging Strategy in INTERMACS 1 Patients Undergoing HeartMate 3 LVAD Implantation

• Published in: The Journal of heart and lung transplantation Vol. 39; no. 4; pp. S419 - S420
• Main Authors: Fried, J.A., Sumzin, N., Witer, L., Kaku, Y., Roth, Z., Masoumi, A., Raikhelkar, J.K., Clerkin, K.J., Griffin, J.M., Sanchez, J., Yuzefpolskaya, M., Kirtane, A.J., Topkara, V., Colombo, P.C., Takayama, H., Naka, Y., Sayer, G.T., Brodie, D., Takeda, K., Uriel, N.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-04-2020
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2020.01.196

Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly used to treat refractory cardiogenic shock, but prior reports have demonstrated poor survival in patients bridged to durable left ventricular assist device (LVAD) with ECMO. The aim of our study was to assess the outcomes of patients bridged with ECMO to HeartMate 3 (HM3) in the contemporary era at a large volume ECMO center.
We retrospectively reviewed 165 consecutive patients implanted with a HM3 at our institution from November 2014 to July 2019. Baseline clinical characteristics, hemodynamic data, and post-operative outcomes were assessed in patients bridged with ECMO to HM 3 and compared to those who were not bridged with ECMO.
Of the 165 patients, 11 patients were bridged to HM3 LVAD using VA-ECMO. Patients supported with ECMO were younger (48.4 ± 13.5 vs. 60.0 ±12.9 yrs, p < 0.01) and had lower hemoglobin (9.0 ± 1.5 vs. 11.8 ± 2.1, p<0.01) and lower platelets (129 ± 70 vs. 189 ± 65, p < 0.01). No differences existed in regards to pre-operative creatinine (1.45 ± 0.75 vs. 1.46 ± 0.45, p=0.60) or intracardiac filling pressures. Median duration of ECMO support was 4 days (IQR 2.5, 5.5). Six patients were supported with a concomitant intra-aortic balloon pump and 2 with Impella. All but 1 patient were extubated on ECMO support. Of the 11 patients, 9 received a temporary surgical RVAD (8 Surgical and 1 Protect Duo). One patient received a HM3 RVAD at time of LVAD implant and another was converted from temporary RVAD to durable HM3 RVAD 50 days following the initial implant. Survival to discharge was 100% and all patients were alive at time of analysis [median time on support 224 days (IQR 106, 390), total 8.53 years of support]. 4 patients underwent heart transplantation between 46 and 670 days following HM 3 implantation.
In carefully selected patients, VA-ECMO is an effective strategy to stabilize critically ill patients as a bridge to HeartMate 3 LVAD. Optimizing end organ perfusion with VA-ECMO prior to surgery and use of an upfront RVAD strategy may result in improved survival in these patients.