The Angiotensin Receptor–Neprilysin Inhibitor is Related to Lower Post-transplant Use of Extracorporeal Membrane Oxygenation

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Background: Extracorporeal membrane oxygenation (ECMO) support after heart transplant is a risk factor for mortality in patients with severe graft dysfunction. Extensive studies have shown that angiotensin receptor–neprilysin inhibitor (ARNI) sacubitril–valsartan has a significant effect on unloading and vascular remodeling in patients with heart failure; however, the impact of ARNIs on heart transplant recipients remains unknown. Methods: This observational, retrospective cohort study included 152 patients who underwent heart transplantation between January 2015 and April 2021. We excluded patients <18 years old and those who underwent re-transplantation or multiple organ transplantation. Patients were divided into two groups based on whether they received an ARNI for at least one month before transplant. The clinical data of recipients and donors from our institutional medical records and the China Organ Transplant Response System were interrogated. Results: In total, 67 patients (mean age, 49.6 years; 81% male) were treated with sacubitril/valsartan before transplant and included in the cohort. The total rate of post-transplant ECMO use was 21.1% (n = 32). Kaplan–Meier survival analysis showed a considerable increase in 6-month mortality in heart transplant recipients supported by ECMO (log-rank p < 0.001). The rate of ECMO use was significantly lower in patients treated with ARNIs than for those who were not (13% vs. 27%; p = 0.041). The multivariate analyses that included three models with different preset covariates demonstrated a lower risk of post-transplant ECMO support in patients receiving the ARNI (all p < 0.05). After propensity score matching, the results also suggested that ARNIs can be a protective factor against post-transplant ECMO support (p = 0.042). Conclusion: Pretransplant use of ARNI agents was associated with a lower risk of ECMO support after HT. Randomized controlled trials are warranted to confirm the effectiveness of ARNIs in improving post-transplant hemodynamics and reducing ECMO use in HT recipients.