Impact of the Pre-Transplant Circulatory Supportive Strategy on Post-Transplant Outcome: Double Bridge May Work.

Nai-Hsin Chi,Shu-Chien Huang,Yih-Sharng Chen,Chih-Hsien Wang,Heng-Wen Chou,Chuan-I Tsao,Kevin Po-Hsun Chen,Hsi-Yu Yu,Nai-Kuan Chou

doi:10.3390/jcm10204697

Abstract

Background: The number of waitlisted patients requiring mechanical circulatory support (MCS) as a bridge to heart transplantation is increasing. The data concerning the results of the double-bridge strategy are limited. We sought to investigate the post-transplant outcomes across the different bridge strategies. Methods: We retrospectively reviewed a heart transplantation database from Jan 2009 to Jan 2019. Intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), and ventricular assist devices (VAD) were the MCS that we investigated. The pre- and post-transplant characteristics and variables of patients bridged with the different types of MCS were collected. The post-transplant survival was compared using Kaplan–Meier survival analysis. Results: A total of 251 heart transplants were reviewed; 115 without MCS and 136 with MCS. The patients were divided to five groups: Group 1 (no MCS): n = 115; Group 2 (IABP): n = 15; Group 3 (ECMO): n = 33; Group 4 (ECMO-VAD): double-bridge (n = 59); Group 5 (VAD): n = 29. Survival analysis demonstrated that the 3-year post-transplant survival rates were significantly different among the groups (Log-rank p < 0.001). There was no difference in survival between group 4(ECMO-VAD) and group 1(no MCS)1 (p = 0.136), or between group 4(ECMO-VAD) and group 5(VAD) (p = 0.994). Group 3(ECMO) had significantly inferior 3-year survival than group 4(ECMO-VAD) and group 5(VAD). Conclusion: Double bridge may not lead to worse mid-term results in patients who could receive a transplantation. Initial stabilization with ECMO for critical patients before implantation of VAD might be considered as a strategy for obtaining an optimal post-transplant outcome.

Highlights

Heart transplantation remains the gold standard for patients with end-stage heart failure (HF) and a poor response to optimal medical therapy [1]
Mechanical circulatory support (MCS) is mandatory to bridge the patients with decompensated heart failure to heart transplantation, and owing to the advancement in mechanical circulatory support (MCS), waiting list mortality has declined in recent years [2]
extracorporeal membrane oxygenation (ECMO) offers the advantages of rapid-implantation, and it is less expensive than ventricular assist devices (VAD) and can be used as a bridge to decision, to candidacy, or to transplantation [8]

Summary

Introduction

Heart transplantation remains the gold standard for patients with end-stage heart failure (HF) and a poor response to optimal medical therapy [1]. Mechanical circulatory support (MCS) is mandatory to bridge the patients with decompensated heart failure to heart transplantation, and owing to the advancement in MCS, waiting list mortality has declined in recent years [2]. Intra-aortic balloon pump (IABP) offers partial circulatory support for advanced heart failure and could be a bridge to VAD implantation or transplantation in some studies [5,6]. Intra-aortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), and ventricular assist devices (VAD) were the MCS that we investigated. Survival analysis demonstrated that the 3-year post-transplant survival rates were significantly different among the groups (Log-rank p < 0.001). Initial stabilization with ECMO for critical patients before implantation of VAD might be considered as a strategy for obtaining an optimal post-transplant outcome

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