The Safety and Efficacy Intra-Aortic Balloon Pump as a Bridge to Transplant Strategy under the New UNOS Allocation

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Introduction We report the safety and efficacy of the IABP as a bridge to orthotopic heart transplantation (OHT) since the United Network of Organ Sharing (UNOS) instituted its updated organ allocation system on October 18th, 2018. Methods This is single-center retrospective analysis reporting the feasibility, safety, and efficacy of the use of IABP as a bridge to OHT. All patients in this study were admitted with cardiogenic shock to the heart failure ICU with an average cardiac index of 1.73±0.22 L/min/m2 and met criteria for hemodynamic support with IABP placement. Results The cohort consisted of 20 consecutive patients with IABP as a bridge to transplant (BTT). Mean age was 50 years old, 65% male, 60% non-ischemic, 20% ischemic, 10% congenital (CC-TGA), and 10% restrictive cardiomyopathy. The rate of successful axillary IABP insertion was 100%, with the majority from a percutaneous approach (15/16) and one via surgical graft. Of the original cohort, 17 patients were successfully bridged to OHT (axillary IABP n=14, femoral IABP n=3), 1 patient who did not have a contraindication to durable MCS received a BTT LVAD after 30 days of IABP support, and 2 patients required upgrade to higher levels of MCS support (Fig 1). All patients with axillary IABP placement ambulated with a physical therapist while awaiting OHT. There were no neurologic events, major bleeding, infections, or death. Balloon rupture necessitating urgent balloon replacement occurred in 15% of patients, and one patient with a femoral IABP required surgical thrombectomy of the common femoral artery. The mean total days with IABP before transplantation or LVAD was 12, with range of 2-30 days (Fig 2). Conclusion Since the recent change in the heart transplant allocation system, we report the largest series, to our knowledge, of patients being bridged to OHT with IABP, the majority of which are axillary. We demonstrate that IABP is a safe and effective platform of support for patients awaiting OHT, and furthermore, we demonstrate the feasibility of the axillary IABP approach.