Single Center Experience with Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Heart Transplant under the Contemporary UNOS Heart Allocation System

Abstract

Purpose Venoarterial extracorporeal membrane oxygenation (VA ECMO) use as a bridge to heart transplant (HTx) has been associated with poor long term outcomes. We investigated our most recent experience with VA ECMO as a bridge to HTx under the new UNOS heart allocation system implemented in October 2018. Methods All HTx that occurred via bridge by VA ECMO between October 1, 2018 to September 30, 2020 at our institution were evaluated. Demographics, cannulation strategy, duration of ECMO, and post-operative outcomes were analyzed. Results Seventy nine patients underwent HTx during this time frame, of which six patients (7.6%) were successfully bridged from VA ECMO. These patients ranged from 19 to 62 years of age, and were supported between four and 42 days (mean 12.2 days). The total hospital length stay was between 34 and 162 days (mean 62.5 days). All patients survived to discharge, and our one month and six month survival are 100%. All patients are still within one year of HTx. No patient had evidence of cerebral vascular accident and/or permanent renal injury requiring sustained hemodialysis. One patient was centrally cannulated for VA ECMO at a referring institution prior to transfer. Five patients were cannulated via a percutaneous approach with Proglide arterial and venous preclosure on opposite access sites, a 5 french antegrade perfusion sheath, and an atrial septostomy for venting. Both centrally and peripherally cannulated VA ECMO patients were ambulated while awaiting HTx. None of the patients undergoing femoral cannulation required open exploration at the time of HTx. Conclusion In this single center dataset, only a small proportion (7.6%) of HTx were bridged via VA ECMO under the 2018 UNOS heart allocation system. Still yet, our short-term results of VA ECMO as bridge to HTx have been promising. When patients require VA ECMO support, we favor a strategy of preclosure, percutaneous femoral access with atrial septostomy with ambulation protocol.