Bridging VA ECMO to Durable MCS: Keys to Success

Abstract

Purpose There is limited data in the literature defining criteria for bridging advanced cardiogenic shock (ACS) patients supported by veno-arterial (VA) ECMO to durable Mechanical Circulatory Support (MCS). We evaluated our screening process on outcomes for all patients at our center bridged from VA ECMO to durable MCS. Methods From September 2014 to October 2018, 153 patients received VA ECMO for treatment of ACS greater than 24 hours. Care was withdrawn from 64 (42%) patients, 68 (44%) were successfully weaned from VA ECMO, 4 (3%) were bridged to extracorporeal biventricular assist device, and 14 (9%) were bridged to durable MCS, which were included in this retrospective analysis. All 14 patients accepted for durable support implantation underwent a multidisciplinary screening process. Criteria for candidacy included 1) acceptable end organ function, 2) extubation, 3) negative infection surveillance, and 4) neurologically intact. To compare clinical status pre VA ECMO and pre MCS, end organ function was assessed by Sequential Organ Failure Assessment (SOFA) score, lactic acid, renal, and hepatic markers. Outcomes assessed included survival and post durable MCS implant hospital length of stay (HLOS). Results As of October 2018, 11 of the 14 patients bridged to durable MCS are still alive (79%). Mean duration of support on VA ECMO before transition was 11 days ± 5 (4-22), and a mean of 343 days ± 312 (28-1041) on durable MCS. The mean post MCS HLOS was 29 days ± 20 (9-90). Of the 14 patients, 11 were transitioned to LVAD. One patient was explanted due to cardiac recovery, 1 received a heart transplant, 1 deceased, and 8 are still on LVAD support. In 2 patients, temporary RVAD support was required post LVAD. Three of the 14 were bridged to Total Artificial Heart, of which 2 have died. Conclusion Applying a thorough screening process to INTERMACS level 1 patients bridged with VA ECMO to durable MCS is a highly successful strategy and yields excellent long-term survival. Our screening process might be a useful guide to bridge select VA ECMO patients to cardiac transplantation.