It's a Long Road to Transplant: A Case of Prolonged ECLS Use as a Bridge to HLT

Abstract

<h3>Introduction</h3> ECLS as a bridge to heart or lung transplantation has become a common practice in the last decade. However, heart-lung transplantation remains an infrequently performed procedure, and reports of ECLS as a bridge to HLT are rare. Poor functional status remains a significant barrier to candidacy for many of these patients. Current guidelines list severely limited functional status and severe malnutrition as contraindications to transplantation. Cardiac prehabilitation includes interventions delivered before surgery with the aim of reducing the incidence or severity of postoperative complications. Cardiac prehab has most often been described in patients awaiting elective surgery, evidence for its use in patients on ECLS awaiting transplantation is absent. <h3>Case Report</h3> A 39-year-old female with idiopathic pulmonary arterial hypertension and atrial septal defect was transferred to our institution in decompensated right ventricular failure requiring peripheral veno-arterial ECMO support. Her course was complicated by differential hypoxemia which necessitated the conversion to V-AV ECMO, thrombosis of distal arterial perfuser resulting in left lower extremity compartment syndrome requiring fasciotomy, sepsis, GI bleeding, and acute kidney injury requiring temporary dialysis. As a result of critical illness and complications, she developed profound deconditioning and malnutrition with a BMI of 15 kg/m² at nadir. The multidisciplinary transplant team developed a comprehensive prehabiliation plan that included intense nutritional support and daily physical therapy. The patient remained on peripheral VA-ECMO support for a total of 111 days. After 99 days of ECLS support, she was listed for HLT. At the time of listing, her BMI was 18, and she was ambulating 150 feet three times per day. She underwent HLT and was discharged home on postoperative day 16. <h3>Summary</h3> We report the first case of prolonged use of peripheral VA-ECMO as a bridge to HLT. Stable hemodynamic and respiratory support with ECLS allowed the patient to undergo intense prehabilitation, resulting in acceptable candidacy for transplantation. A multidisciplinary approach with the involvement of physicians, nurses, dietitians, and physical and occupational therapists is critical to fully optimize functional and nutritional status in complex patients supported with ECLS as a bridge to transplantation.