Immediate ECMO Initiation Leads to Graft Recovery in Delayed Graft Failure after Heart Transplant

Abstract

<h3>Introduction</h3> Graft failure is a leading cause of thirty-day mortality for heart transplant (HTx). Primary graft dysfunction, defined as occurring within 24 hours of transplantation, is the most frequent cause of graft failure. We present a rare case of delayed graft failure, which occurred on postoperative day (POD) 9, of unknown cause successfully recovered by immediate veno-arterial extracorporeal membrane oxygenation (VA-ECMO) initiation and subsequent biventricular assist device (BiVAD) support. <h3>Case Report</h3> A 55-year-old male with end stage heart failure from ischemic cardiomyopathy and severe peripheral vascular disease (PVD) underwent successful HTx surgery. On POD 6, he was transferred out of the ICU in stable condition. His POD 6 transthoracic echocardiogram (TTE) showed left ventricular ejection fraction (LVEF) of 60% with mild-moderately reduced right ventricular (RV) function. On POD 9, the patient went into sudden cardiac arrest, with return of spontaneous circulation after cardiopulmonary resuscitation. VA-ECMO was initiated immediately afterward, with right axillary arterial percutaneous cannulation due to severe PVD. A subsequent TTE showed LVEF of 5%, and a nearly akinetic RV, concerning for delayed graft failure. The patient was transitioned to extracorporeal BiVAD support on POD 21. A biopsy taken POD 21 showed non-infective myocarditis with no evidence of rejection. Prior to BiVAD explant (POD 78), TTE showed improved heart function: LVEF of 45% and only moderately reduced RV function. The BiVAD was explanted after 63 days of support. He was discharged 34 days after BiVAD explant; the presumed cause of delayed graft failure was secondary to residual pulmonary hypertension post-HTx. <h3>Summary</h3> In a case of rare delayed graft failure of unknown cause, immediate VA-ECMO initiation, followed by proper MCS management successfully rescued graft function.