Transition from Short-Term to Durable Mechanical Circulatory Support Systems. Outcome and Patient Selection. On Behalf of ECMO-VAD Study Group

Abstract

Purpose The implantation of durable ventricular assist devices (VAD) in patients on veno-arterial membrane oxygenation (VA-ECMO) is controversial. Available studies in this field are limited to anecdotal case reports. In this study, data of ten high volume VA-ECMO/VAD centers are collected and analysed. Methods Following approval from corresponding ethic committees, data of patients undergoing durable mechanical circulatory support implantations at ten institutions between 01.2010 - 07.2018 were reviewed. Inclusion criteria are patients with prior VA-ECMO support. Several parameters including patient´s characteristics, results of blood gas analysis, blood chemistry, and catecholamine doses prior to the assist device surgery are collected and analysed. The primary endopint was survival or cardiac transplantation at one year. Results A total of 494 patients met the inclusion criteria. The average age was 53 ± 12 yrs. The majority of the patients (82%) were male and 33% of the patients had cardiopulmonary resuscitaion prior to the VA-ECMO implantation. The mean VA-ECMO support duration prior to durable device implantation was 7 ± 8 days. Up to 34 % of the patients were on renal dialysis. Cardiopulmonary bypass was used in 63% of the patients at the time of durable device surgery. Less invasive VAD implantation was performed in 19% of the patients. Type of implanted pump included HeartWare HVAD (70%), HeartMate II (17%), HeartMate III (8%), CardioWest TAH (3.6%) and other pumps in (1.4%). The 30 day, 1 year and 2 year survival was 75 and 50% and 40% respectively. Postoperative complications included right heart failure requiring right VAD in 41% of patients, bleeding requiring resternotomy in 38%, respiratory failure in 65%, renal failure in 68% and hepatic failure in 35% of the patients. Stroke rate was 21%. Heart transplantation was performed in 33% of the patients. Conclusion In this largest ever reported series of durable assist device patients with prior VA-ECMO support, higher rate of postoperative right ventricular failure and bleeding /end organ function complications are observed compared to elective VAD implantations. Nevertheless, considering preoperative characteristics of these patients, acceptable outcome of 50% 1 year success was achieved.