Outcomes of ECMO versus VAD in Children with Congenital Heart Disease as a Bridge to Transplant in Recent Era: Analysis from United Network for Organ Sharing Database

Abstract

<h3>Purpose</h3> To compare the clinical characteristics, risk factors, and overall survival (waitlist and post-transplant) outcomes in children with congenital heart disease (CHD) bridged to transplantation with either a VAD vs. ECMO vs. no-mechanical circulatory support (MCS). <h3>Methods</h3> The study included 2899 primary heart transplantations in children <18 years with CHD between 2010 and 2019 from the UNOS database. Patients who had ECMO or VAD at listing or while listed were included and their waitlist and post-transplant outcomes compared with CHD patients who did not require MCS. <h3>Results</h3> Of all, 466(16%) had ECMO and 200(7%) VAD at the time of listing or while listed (Figure-1 A-B). There was an increasing VAD utilization trend during the last decade over ECMO (<i>p</i><0.01). The 90 days post-MCS survival was better with the use of VAD compared to ECMO (67% vs. 49%, p<.01) (Figure-2). More patients in the VAD group (70%) were transplanted compared to ECMO (47%), the transplantability rate was decreased with older age (odds ratio (OR), 0.91; 0.95% confidence interval (CI), 0.86-0.95), lower BMI (OR, 0.93; 95% CI, 0.89-0.98) and lower albumin < 3g/dL (OR, 0.6; 95% CI, 0.53-0.7). Multivariate model predicted that lower BMI (OR, 1.12; 95% CI, 1.06-1.18), pre-transplant ECMO (OR, 2.19; 95% CI, 1.39-3.45), and higher bilirubin (OR, 1.15; 95% CI, 0.97-1.36) decreased 1-year post-transplant survival. Patients transplanted with VAD had better 1-year survival than ECMO (88% vs. 70%, p=0.01) (Figure-3). <h3>Conclusion</h3> Waiting list survival of children with CHD supported by durable VAD is better compared to ECMO support. The long-term posttransplantation outcomes of CHD patients supported by VAD is similar to non-MCS patients and better than ECMO supported patients. The transition from ECMO to VAD while listed results in similar outcomes to VAD-first, so every effort should be made to select CHD patients eligible for VAD as a bridge to transplantation.