EARLY CIRCULATORY SUPPORT WITH EXTRACORPOREAL MEMBRANE OXYGENATION IMPROVES OUTCOMES AFTER SEVERE GRAFT DYSFUNCTION

Abstract

Primary or secondary graft dysfunction (GD) is the main cause of early mortality after orthotopic heart transplantation (OHT). We hypothesize that early implantation of temporary circulatory support with veino-arterial extracorporeal membrane oxygenation (V-A ECMO) in patients who had post-transplant PGD is associated with a better survival. The purpose of this study was to compare characteristics and outcomes of patients who underwent an early implantation versus a delayed implantation of ECMO after PGD. All patients who received a V-A ECMO for severe graft dysfunction after OHT in two institutions between 2003 and 2013 were retrospectively reviewed. Among the 280 patients who underwent OHT, 63 patients (22%) needed ECMO. Patients were divided in two groups: early group (n=39; implantation before 24h) and delayed group (n=24; implantation after 24h). In the entire cohort, the mean age was 48±13 years and 84% were male. Etiologies of graft failure were right heart failure without (n=33/63-52%) or with severe pulmonary hypertension (n=26/63-25%), primary graft failure (n=24/63-38%). Fourteen patients had ECMO before OHT: 12 patients (38%) were in the early group and 2 (8%) in the delayed group (p=0.06). Other preoperative characteristics of recipients were not different between the two groups. Donor characteristics were also similar despite a longer ischemia time in the early group (245±11 vs. 189±13 min, p=0.001). The time between OHT and ECMO implantation was 3.2±2 hours in the early group vs. 38.2±10.2 hours in the delayed group. In the early group, patients had longer cardiopulmonary bypass time (195±9 vs. 138±9, p=0.001) and lower doses of adrenalin and noradrenaline before ECMO implantation (0.62±0.2 vs. 2.6±1.1 mg/h, p=0.06 and 0.24±0.1 vs. 5.5±2.1 mg/h, p=0.003). Mean duration of support (7.3±9.0 days) was similar in the 2 groups. Hospital mortality was significantly lower in the early group (n=6/34-18% vs. n=11/24-58%, p=0.003). There was no difference in terms of major complications of ECMO between the 2 groups. The 1-year survival was 67% in the entire cohort and was significantly higher in the early group (79% vs. 16%, p=0.006) (Figure). Early implantation of a temporary mechanical support with ECMO is associated with better survival in patients with severe GD after cardiac transplantation. Liberal use of ECMO in these patients should be promoted.