Clinical Outcomes and Financial Implications of Using Extra Corporeal Membrane Oxygenation (ECMO) for Primary Graft Dysfunction Following Heart Transplantation: A Single Centre Experience

Abstract

Primary graft dysfunction (PGD) after heart transplant is associated with high morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) can be used to wean patients from cardiopulmonary bypass and provides the opportunity to rest the transplanted heart until it regains function. This study retrospectively reviews a single centre experience of post-transplant ECMO in regard to outcomes and associated costs. Between May 2006 and May 2019, 267 adult heart transplants were performed. We compared donor and recipient variables, ECMO duration and the incidence of renal failure, bleeding and infection between ECMO and non-ECMO groups. Economic analysis was performed to determine differences in cost for equipment, blood transfusion, renal dialysis, and critical care/postoperative ward stay. ECMO support was required postoperatively to manage PGD in 72 (27%) patients. The mean duration of ECMO support was 6 ± 3.2 days. Donor and recipient demographic variables, including mean ischaemic time were similar between the groups. ECMO patients were associated with longer duration of stay in CCU (p<0.0001) and total hospital stay (p<0.0001). ECMO patients more frequently developed renal failure (p<0.0001), postoperative bleeding (p<0.0001), had a higher re-exploration rate (p<0.0001), and a higher rate of infection (p<0.0001) compared with the non-ECMO group. Greater mortality was observed in the ECMO group (p<0.0001). The mean cost of providing ECMO was £18,250±7,396 per patient with an additional £49,637.90 for CCU stay whilst on ECMO. The total mean cost per patient inclusive of hospital stay, ECMO and dialysis costs was £85,944±58,180 in the non-ECMO group compared to £178,056±137,026 per patient in the ECMO group (p<0.0001). Extracorporeal membrane oxygenation support can be utilised for management of PGD following heart transplantation. Patients with PGD following heart transplantation who require ECMO are frequently bridged to a recovery, however, the medium and longer-term survival for these patients is poorer than for patients who have no requirement for ECMO. It remains unclear whether this inferiority is related to donor/recipient related factors or ECMO-related effects are implicated.