Strategy for prophylactic application of peripheral va-ecmo in transplantation involving expected extremely prolonged ischemia time

Abstract

Heart transplantation (HT) with extremely prolonged (>6 hours) graft ischemia is associated with severe cardiac graft dysfunction. The high efficiency of prophylactic (preoperative initiation) veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to prevent severe hemodynamic disorders during cardiac surgery has been demonstrated. Objective: to determine the effect of prophylactic VA-ECMO on the perioperative period in HT with an expected graft ischemia >6 hours. Materials and methods. Thirty-eight recipients (33 (86.8%) males and 5 (13.2%) females), age 11–66 (44.7 ± 12.0) years (median 48.0 years) were examined. Pre-transplant mechanical circulatory support (MCS) using peripheral VA-ECMO was applied in 15 (39.5%) recipients, in 6 of whom by prophylactic technique. The recipients (n = 38) were divided into 3 groups: 1) «no pre-HT VA-ECMO» (n = 23); 2) «pre-HT VA-ECMO» (n = 9) – pre-transplant VA-ECMO as a bridge to HT; 3) «prophylactic VA-ECMO» (n = 6). Results. In «prophylactic VA-ECMO» group, extracorporeal circulation (ECC) (94.0 [85.5; 102.8] min) and reperfusion time (20.0 [18.3; 27.6] min) were shorter (p < 0.05) compared to «no pre-HT VA-ECMO» (161.0 [122; 191.5] and 60.0 [55.3; 70.5] min) and «pre-HT VA-ECMO» (127.0 [117; 150.3] and 35.0 [27.8; 48.8] min) groups. The vasoactive-inotropic score was lower (p < 0.05) in «pre-HT VA-ECMO» and «prophylactic VAECMO» groups compared to recipients in «no pre-HT VA-ECMO» group, 12.1 [11.2; 14.0] and 12.5 [11.7; 14.8] vs. 16.0 [15.0; 18.5], respectively. The groups did not differ in terms of incidence of severe primary dysfunction. The «pre-HT VA-ECMO» and «prophylactic VA-ECMO» groups were characterized by shorter duration of mechanical ventilation (MV) compared with «no pre-HT VA-ECMO» group (11.7 [10.0; 16.5] and 12.7 [11.3; 18.4], respectively, vs. 14.5 [13.0; 19.3]). The «no pre-HT VA-ECMO» and «prophylactic VA-ECMO» groups did not differ in the need for postoperative MST, 21.7% and 16.7%, respectively. The groups did not differ in terms of length of stay in the intensive care unit (ICU) and in-hospital mortality – 0% («prophylactic VA-ECMO») and 8.7% («no pre-HT VA-ECMO») and 11.1% («pre-HT VA-ECMO»), respectively. Conclusion. Prophylactic VA-ECMO in HT with extremely prolonged cardiac graft ischemia reduces ECC duration, reperfusion period, postoperative mechanical ventilation period, and the need for inotropic therapy.