Safety of Mechanical Support via the Axillary Artery as a Bridge to Orthotopic Heart Transplantation

Abstract

Intra-aortic balloon pumps (A-IABP), Impella, and the intravascular ventricular assist system (iVAS) are being utilized as bridges to orthotopic heart transplantation (OHT). Benefits of an axillary approach include allowing patients to ambulate prior to transplantation. The purpose of this case series is to examine the safety of this approach as a bridge to OHT since the implementation of the new UNOS donor heart allocation schema in October 2018. We retrospectively reviewed all patients who underwent implantation of an intra-axillary mechanical assist device as a bridge to OHT from December 2018 until August 2019 at a single institution. All devices were inserted via surgical grafts sewn directly to the axillary artery. Primary outcome of interest was successful bridge to OHT. Secondary outcomes included death, time to OHT, stroke, and vascular complications. Ten patients were included in the series: 7 treated with A-IABP, 1 with Imeplla, and 2 with iVAS (Figure 1). Mean age was 56 and 20% were female. In the A-IABP group, 5 were implanted in the left axilla and 2 in the right. The proximal right axillary artery was used for Impella and iVAS access. There were no axillary approach related morbidities nor any neurologic or vascular complications. However, 2 patients with A-IABP required return to the OR for A-IABP reimplantation due to device malfunction. 6 patients with A-IABP survived to OHT with mean time to transplant of 25 days (Range: 6-68). One A-IABP and the Impella patient survived to OHT after conversion to CentriMag. 1 iVAS patient survived to OHT after 29 days and 1 is waiting at home for OHT. There is growing interest in the use of intra-axillary mechanical support devices in patients awaiting OHT. This approach has the advantage of improved mobility while maintaining adequate hemodynamic support. The use of axillary mechanical support in this series was associated with successful bridge to transplant in all patients.