(671) - Extracorporeal Membrane Oxygenator Bridge To Ventricular Assist Device Implantation for Patients in Profound Cardiogenic Shock Achieves Stabilization and Improved Results

Abstract

In patients requiring left ventricular assist device (LVAD) support, acuity of presentation has been shown to be a predictor of outcomes. Those in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 status demonstrating a mortality risk of 14% with an interval improvement in mortality of 17% with each successive INTERMACS level. (3) INTERMACS 1 status patients are difficult to stratify for viability of long-term support with LVAD and beyond. Even in the absence of contraindication to LVAD, institution of LVAD in a shocked patient is associated with high morbidity and mortality. In such situations, interest is growing in the utilisation of veno-arterial extracorporeal membrane oxygenator (VA-ECMO) as a bridge-to-bridge support for these critically unwell patients. We conducted a retrospective review of all consecutive patients implanted with LVAD at a single quaternary referral centre from January 2010 to June 2013. 53 patients presented requiring LVAD. All patients received third-generation devices. Of these, 48 were implanted as bridge-to-transplantation, 3 were implanted as destination therapy, and 1 as a bridge-to-decision. 36.5% (n=19) required urgent pre-VAD ECMO due to cardiogenic shock. There was 1 in hospital death in the ECMO group (1/19 [5.2%]) and 1 in the LVAD group not requiring ECMO (1/34 [2.9%]p=0.33). This is despite the ECMO group having a higher presenting APACHE 3 score (mean 66 +/- 11.533 vs. 52.485 +/- 6.103, p=0.021) and higher incidence in pre-operative haemofiltration (31.6% vs. 6.1%, p=0.0156) and ventilatory support (75% vs. 13.8%, p=0.0001). The incidence of RV failure was 46.2% (n=24, 12 per group). There were no differences between groups in bleeding, return to theatre, inotrope use, nitric oxide use or ventilator support. These results suggest that, despite presenting more acutely unwell, patients supported on VA-ECMO as bridge to longer term VAD support have outcomes which are comparable with those not requiring ECMO prior to LVAD. The ECMO bridge to LVAD support can stabilize high risk INTERMACS 1 status patients with an improved outcome after LVAD implantation compared to published outcomes in these ‘crash and burn’ patients.