Long-term Ventricular Assist Device Research Articles

(1075) - Medium to Long-Term Ventricular Assist Device Support in Adults with Congenital Heart Disease: The Baylor St. Luke’s Medical Center / Texas Children’s Hospital Experience

(1075) - Medium to Long-Term Ventricular Assist Device Support in Adults with Congenital Heart Disease: The Baylor St. Luke’s Medical Center / Texas Children’s Hospital Experience

Biofunctionalization of surfaces to minimize undesirable effects in cardiovascular assistance devices.

The reactivity of blood with non-endothelial surface is a challenge for long-term Ventricular Assist Devices development, usually made with pure titanium, which despite of being inert, low density and high mechanical resistance it does not avoid the thrombogenic responses. Here we tested a modification on the titanium surface with Laser Induced Periodic Surface Structures followed by Diamond Like Carbon (DLC) coating in different thicknesses to customize the wettability profile by changing the surface energy of the titanium. Four different surfaces were proposed: (1) Pure Titanium as Reference Material (RM), (2) Textured as Test Sample (TS), (3) Textured with DLC 0.3μm as (TSA) and (4) Textured with 2.4μm DLC as (TSB). A single implant was positioned in the abdominal aorta of Wistar rats and the effects of hemodynamic interaction were evaluated without anticoagulant drugs. After twelve weeks, the implants were extracted and subjected to qualitative analysis by Scanning Electron Microscopy under low vacuum and X-ray Energy Dispersion. The regions that remained in contact with the wall of the aorta showed encapsulation of the endothelial tissue. TSB implants, although superhydrophilic, have proven that the DLC coating inhibits the adhesion of biological material, prevents abrasive wear and delamination, as observed in the TS and TSA implants. Pseudo- neointimal layers were heterogeneously identified in higher concentration on Test Surfaces.

Cardiological Challenges Related to Long-Term Mechanical Circulatory Support for Advanced Heart Failure in Patients with Chronic Non-Ischemic Cardiomyopathy.

Long-term mechanical circulatory support by a left ventricular assist device (LVAD), with or without an additional temporary or long-term right ventricular (RV) support, is a life-saving therapy for advanced heart failure (HF) refractory to pharmacological treatment, as well as for both device and surgical optimization therapies. In patients with chronic non-ischemic cardiomyopathy (NICM), timely prediction of HF's transition into its end stage, necessitating life-saving heart transplantation or long-term VAD support (as a bridge-to-transplantation or destination therapy), remains particularly challenging, given the wide range of possible etiologies, pathophysiological features, and clinical presentations of NICM. Decision-making between the necessity of an LVAD or a biventricular assist device (BVAD) is crucial because both unnecessary use of a BVAD and irreversible right ventricular (RV) failure after LVAD implantation can seriously impair patient outcomes. The pre-operative or, at the latest, intraoperative prediction of RV function after LVAD implantation is reliably possible, but necessitates integrative evaluations of many different echocardiographic, hemodynamic, clinical, and laboratory parameters. VADs create favorable conditions for the reversal of structural and functional cardiac alterations not only in acute forms of HF, but also in chronic HF. Although full cardiac recovery is rather unusual in VAD recipients with pre-implant chronic HF, the search for myocardial reverse remodelling and functional improvement is worthwhile because, for sufficiently recovered patients, weaning from VADs has proved to be feasible and capable of providing survival benefits and better quality of life even if recovery remains incomplete. This review article aimed to provide an updated theoretical and practical background for those engaged in this highly demanding and still current topic due to the continuous technical progress in the optimization of long-term VADs, as well as due to the new challenges which have emerged in conjunction with the proof of a possible myocardial recovery during long-term ventricular support up to levels which allow successful device explantation.

Long-Term Ventricular Assist Devices – Main Complications in Contemporary Clinical Practice

Advanced heart failure (HF) is associated with reduced quality of life and high hospitalization and mortality rates. Ventricular assist devices (VADs) promote an increase in cardiac output, and consequently improvements in body functions, functional capacity and patient survival. However, the use of VAD may be associated with complications and require systematic and specialized care. Ischemic and hemorrhagic stroke is among the most feared complications and its occurrence is related to thrombus formation in the pump. The connection between the [...]

Long-Term Ventricular Assist Devices: Where are We in Brazil?

Long-Term Ventricular Assist Devices: Where are We in Brazil?

Brazilian Unicentric Experience of Implanting Long-Term Ventricular Assist Devices

Purpose In the past 20 years, long term ventricular assist devices (LVAD) have become part of long-term therapy in patients with advanced heart failure (HF), with an increasing number of implants in worldwide. However, the implantation of LVAD for patients with advanced HF in Brazil requires high investment and specialized technical knowledge, which hinders the availability of this resource. We will analyse the outcomes as mortality, quality of life and complications of using LVAD in patients with advanced HF at a cardiology center in Brazil. Methods Data based on analysis of medical records with the clinical characteristics, outcomes and complications of patients who underwent LVAD implantation in the last 7 years, as well as mortality in 1 year and improvement in functional capacity. Results 23 LVAD (Berlin Heart INCOR®, Heart Mate II and Heart Mate III) were implanted in patients with advanced HF. 52% of the patients were male, with a mean age of 53 years, 39% had ischemic heart disease and 70% had INTERMACS 3. The mean left ventricular ejection fraction was 24%. Among the indications for implantation of LVAD, 65% were as destination therapy, 17% as a bridge for heart transplantation due to the expectation of long queuing time and 17% as a bridge for candidacy. The 1-year survival was 66% and after 6 months of LVAD, 95% were in NYHA I. The average length of stay with the device was 445 days and the maximum time was 1066 days. The main causes of death were hemorrhagic shock, right ventricle failure and stroke. Four patients underwent for LVAD explant, three of whom were transplanted. Of all cases, 83% were discharged from hospital, with an average hospital stay of 47 days after implantation. Conclusion Despite requiring high financial resource and notorious technical quality, this therapy is feasible in a country with high incidence of advanced HF, providing shorter hospital stays, high 1-year survival rate and significant improvement in quality of life.

Psychosocial outcomes in pediatric patients with ventricular assist devices and their families: A systematic review.

Ventricular assist device (VAD) therapy has provided pediatric patients with severe heart failure new therapeutic options. However, pediatric patients and families receiving VAD therapy also experience psychosocial challenges. No synthesis of the literature on psychosocial outcomes within the pediatric VAD population has been conducted; thus, the current review sought to systematically investigate the impact of pediatric VAD on patient, parent, and family psychosocial outcomes and assess variables associated with poorer outcomes. Literature searches were conducted in PsycInfo, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases and full texts were assessed according to pre-established inclusion criteria. Main findings and study quality were reviewed. Sixteen studies were included in the present review. Findings highlighted the likelihood for psychological sequelae among pediatric patients and families receiving VAD therapy, including decreased psychological and emotional well-being, elevated stress, and difficulty coping with changes to family dynamics and responsibilities. Health-related quality of life was reported comparable to that of healthy peers and children with other cardiac conditions. Patients and families on VAD therapy experience significant difficulties in psychological well-being and challenges related to adjustment. The current review underscores the importance of ongoing support for families and continued assessment of psychosocial functioning across VAD support. Three critical periods for increased distress were identified: 1) immediately following VAD implantation, 2) discharge home and the weeks following discharge, and 3) long-term VAD therapy.

Genetic Testing Could Assist in the Clinical Management in Patients Supported on Ventricular Assist Devices With Recovered Myocardial Function

The long-term management of patients where myocardial function recovers post ventricular assist device (VAD) implant remains controversial due to the insufficient knowledge of the clinical trajectory long-term post VAD explant. We describe two cases where genetic testing assisted our decision for VAD explantation versus transplantation.

Rotary Ventricular Assist Device Control With a Fiber Bragg Grating Pressure Sensor

Current ventricular assist devices (VADs) are rotary blood pumps used to treat end-stage heart failure. VADs are operated at a constant speed that is manually adjusted by a clinician based on the patient's cardiac demand during routine medical examinations. VADs operated at a constant speed have inadequate passive flow regulation due to the inherent mechanical pressure-flow characteristics of the pump; this can lead to harmful situations where the VAD is overpumping or underpumping. Typically, patients on long-term VAD support are discharged to an outpatient setting where the VAD speed can remain the same for weeks or months at a time, impacting patient safety and quality of life. Previously, physiological controllers for VADs have been proposed, which automatically adjust VAD speed to meet patient cardiac demand. Clinical implementation of physiological control is currently hindered by the lack of clinically available, implantable, and continuous hemodynamic sensors. This study describes the physiological control of a VAD using a fiber Bragg grating (FBG) sensor previously developed for measuring VAD inlet pressure. The FBG sensor was used as a feedback to a Starling-like physiological controller, and the control quality was compared against the same controller with feedback from a nonimplantable industrial pressure sensor (Omega sensor). Experiments were conducted in a bench-top cardiovascular simulator under various simulated patient scenarios. The average steady-state difference in VAD flow across all experiments was 0.1 L/min with a maximum difference of -0.4 L/min. Similarly, the average steady-state difference in left ventricular end-diastolic pressure was 0.02 mmHg with a maximum difference of -0.2 mmHg. The clinically insignificant differences found between the two feedback methods indicate that the FBG pressure sensor is viable for the physiological control of VADs.

Post-Discharge Quality of Life with a Long-Term Ventricular Assist Device: Focus on Functional Disability and Impact of Health Status

Reported outcomes after left ventricular assist device (LVAD) implantation include mortality, hospital readmission and severe adverse events. We have less information about patients' perceptions of their quality of life (QOL) after hospital discharge. We conducted a prospective two-center international pilot study to assess at-home functional capacity and QOL following LVAD implantation as a bridge to transplant (BTT) or destination therapy (DT). 124 patients ≥ 30 days after discharge post-implantation were assessed telephonically or during on-site clinic visits. WHODAS 2.0 assesses disability in cognition, mobility, self-care, interpersonal relationships, work/household roles and societal participation. EQ-5D assesses impact of health status on 5 life dimensions. EQ-VAS reflects health self-assessment from 0-100 (worst to best imaginable). Mean patient age was 57.5±15.2 yrs; 15% female; 47% >1 yr post-implantation; 56% DT; 67% had HeartMate 3. Disability was minimal in 67% but moderate to severe in 33% (Figure). In the EQ-5D, moderate to extreme problems were reported with usual activities (33%), pain (32%), mobility (31%), self-care (24%) and anxiety (22%). At assessment, 42% reported an EQ-VAS ≥70, but 25% reported <50. 96% of patients in the best quintile of EQ-VAS reported no or mild disability (p < 0.01), but so did 30% of patients in the worst quintile. The majority of LVAD out-patients reported good functional capacity, little impact of their health on major life domains, and high subjective health self-assessment. Yet a substantial minority did not enjoy a high QOL. A good EQ-VAS correlates with high functional ability, but some patients have a poor EQ-VAS even without disability. Routine assessment of functional ability and health status is feasible in post-discharge LVAD patients. Standardized, regular assessments could help us identify factors associated with a high versus low QOL.

Post-Discharge Quality of Life in Patients Receiving a Long-Term Ventricular Assist Device: Focus on Anxiety, Depression and Post Traumatic Stress Disorder

Reported outcomes after left ventricular assist device (LVAD) implant include mortality, hospital readmission and severe adverse events. We have less information about patients' perceptions of their quality of life (QOL) after hospital discharge. We conducted a prospective two-center international pilot study to assess anxiety, depression and post-traumatic stress disorder (PTSD) following LVAD implant as bridge to transplant (BTT) or destination therapy (DT). 124 patients ≥ 30 days after discharge post-implant were assessed telephonically or during on-site clinic visits. GAD-7 is a 7 item scale assessing anxiety; PHQ-9 is a 9 item scale assessing depression; and IES-R is a 22 item scale reflecting self-described symptoms of PTSD. EQ-VAS is a 1 item response reflecting health self-assessment from 0-100 (worst to best imaginable). Mean patient age was 57.5±15.2 yrs; 15% female; 47% >1 yr post-implantation; 56% DT; 67% had HeartMate 3. High scores for anxiety and depression (some with suicidal ideation) warranted further evaluation in 18% and 8% of patients respectively. Risk of severe anxiety was higher in patients < 60 yrs (p <0.01). 23% of patients had scores consistent with PTSD, and in 80% of these it was moderate to very severe. The risk of anxiety, depression and PTSD was highest in the patients with EQ-VAS <50 (p <0.05) (Figure). No differences related to gender or LVAD strategy. Although the majority of LVAD out-patients reported low levels of anxiety, depression and did not exhibit symptoms of PTSD, an important minority had symptoms severe enough to warrant evaluation for therapeutic intervention. A low EQ-VAS may be helpful in identifying patients at risk but does not specify its nature or severity. Standardized, regular assessments with GAD-7, PHQ-9 and IES-R may help to identify patients in urgent need of evaluation for severe anxiety, depression (including suicidal ideation) and PTSD.

Bivalirudin Experience in a Heterogeneous Ventricular Assist Device Population

Ventricular assist devices (VADs) are an increasingly common therapy for end-stage heart failure across all ages as a bridge to recovery or transplant and more recently as destination therapy. With increasing experience and difficulties with establishing therapeutic heparin levels, we have begun to explore the effectiveness of direct thrombin inhibitors in this patient population. This is a retrospective review of all long-term VAD patients, both adult and pediatric, who were anticoagulated with bivalirudin between January 2009 and January 2016. The starting dose was 0.3 mg/kg/hr, and dose was titrated for a goal partial thromboplastin time (PTT) of 70-100. There were 14 patients (13 males, 5 ≤18 years) with 17 episodes of bivalirudin therapy. The median age on initiation was 45 years (range, 15 days-67 years) with 10 episodes associated with a HeartWare HVAD, five a HeartMate II, and two with a Berlin Heart EXCOR. The predominant indication of bivalirudin therapy was suspected pump thrombosis (13/17). The median time from VAD insertion to initiation of bivalirudin was 116 days (range, 3-1,870) with the median duration of therapy being 21 days (range, 3-113). In patients with pump thrombosis, the mean baseline lactate dehydrogenase (LDH) was 229 ± 64 U/L, peak 690 ± 380 U/L, and decreased to 330 ± 243 U/L when bivalirudin was stopped. The outcomes following suspected pump thrombosis included: transitioned to warfarin (n = 7), death in two destination therapy patients who did not undergo pump exchange, transplantation (n = 2), and pump exchange (n = 2). A major bleeding complication occurred in only one patient. Our experience highlights the potential use of bivalirudin in a heterogenous VAD population. Although these initial results suggest some potential role for direct thrombin inhibitors for use in long-term VADs, larger prospective studies are required to support these preliminary observations and to determine who may benefit from direct thrombin inhibitors (DTIs) and the side effect profile in this patient population.

A novel fibre Bragg grating pressure sensor for rotary ventricular assist devices

Ventricular assist devices are used to support patients with end-stage heart failure. Many patients on long-term VAD support are treated out-of-hospital where monitoring technology for patients is severely limited; leading to sub-optimal patient management. This paper describes a novel fibre Bragg grating (FBG) pressure sensor which was developed for improved monitoring of patients with ventricular assist devices. The FBG sensor was fabricated in-house and characterised in a circulating heat bath. The FBG pressure sensor demonstrated a sensitivity of −0.0046 nm/mmHg with an accuracy of ± 0.35 mmHg, a resolution of 0.0019 mmHg and a response time of 89.7 mmHg/s. The high sensitivity and resolution combined with the adequate accuracy exhibited by the FBG sensor demonstrated its potential value of the FBG pressure sensor for monitoring patients with ventricular assist devices. Further investigation into device drift, improved manufacturing, and gas-impermeable biocompatible materials are required to prepare the sensor for pre-clinical trials.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

Stop the Leak! Transcatheter Aortic Valve Replacement in Pediatric VAD Patient

Introduction Recognition of ventricular assist device (VAD) complications such as aortic insufficiency (AI) are important to optimize long-term management. We highlight a case of the treatment of severe AI in a pediatric continuous flow (CF) VAD patient using transcatheter aortic valve replacement (TAVR). Case Report A 9-year-old male with congenitally corrected transposition of the great arteries and pulmonary atresia underwent staged surgical palliation including a Mustard and Rastelli operation. He developed severe left ventricular (LV) dysfunction with refractory heart failure and underwent implant of a HeartWare (Medtronic, Minneapolis MN) in the morphologic LV on the right side at almost 5 years of age (weight 13.7 kg, BSA 0.64 m2). His waitlist time was prolonged due to significant allosensitization. After 4 years on support, clinical signs of congestive heart failure (CHF) developed and BNP rose (1000 pg/mL) despite optimal VAD performance. Cardiac catheterization showed severe AI and pulmonary hypertension. Mean pulmonary arterial pressure was 40 mmHg with pulmonary vascular resistance of 8.5 WUm2 that was responsive to pulmonary vasodilators. The pulmonary hypertension was attributed to the AI. To avoid a difficult redo sternotomy, TAVR was deemed the optimal way to replace his aortic valve. He underwent catheterization and a 29 mm Edwards SAPIEN 3 valve (Edwards Lifesciences, Irvine CA) was placed in the aortic valve position via right carotid artery cut down using a 21 French sheath. The VAD speed was reduced to 1800 RPM and rapid ventricular pacing allowed for stabilization during valve deployment. Post TAVR, angiography showed resolution of AI with only mild perivalvar leak around the aortic valve. After discharge, he was noted to have a transient rise in lactate dehydrogenase from baseline and increased bruising due to unclear etiology. Within 5 months of his TAVR, his diuretics were weaned with marked improvement in his BNP and resolution of his CHF. Summary AI is a significant complication of long-term CF VAD support that can lead to detrimental hemodynamics and worsening CHF. TAVR may be a reasonable therapy to mitigate AI in high-risk children.

Stem Cell and Left Ventricular Assist Device Combination Therapy.

Ventricular assist device (VAD) technology has evolved significantly over the past decades and currently represents one of the most important treatment strategies for patients with advanced chronic heart failure. There is increasing evidence that in selected patients undergoing long-term VAD support, improvement of myocardial structure and function may occur. However, there seems to be a significant discrepancy between structural and functional recovery of the failing myocardium, as only a small fraction of VAD-supported patients demonstrate reverse structural remodeling and eventually reach clinically significant and stable, functional improvement. More recently, cell therapy has gained a growing interest in the heart failure community because of its potential to augment reverse remodeling of the failing myocardium. Although theoretically the combination of long-term VAD support and cell therapy may offer significant advantages over using these therapeutic modalities separately, it remains largely unexplored. This review aims to summarize the current state of the art of the effects of VAD support and cell therapy on the reverse remodeling of the failing myocardium and to discuss the rationale for using a combined treatment strategy to further promote myocardial recovery in patients with advanced chronic heart failure.

Temporary mechanical circulatory support for refractory heart failure: the German Heart Center Berlin experience.

Temporary mechanical circulatory support (MCS) offers a valuable option for treatment of refractory heart failure. We present our experience with selected MCS devices in cardiogenic shock of different etiologies. We retrospectively studied patients who were treated in our institution between 01/2016 and 07/2018. Patients receiving only veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support were excluded. Left ventricular support patients received Impella; right ventricular support was conducted using Levitronix CentriMag. Thirty-seven patients received an Impella left ventricular assist device (LVAD). Etiology was: acute on chronic ischemic cardiomyopathy (ICMP; n=12), acute myocardial infarction (AMI; n=11), dilated cardiomyopathy (DCMP; n=7) and toxic cardiomyopathy (TCMP; n=2). Two patients presented with postcardiotomy shock and acute myocarditis, respectively. In one case, Takotsubo cardiomyopathy was diagnosed. Impella was used solely in 28 patients (Impella group) with an in-hospital survival of 37%. In nine patients, Impella was used in combination with extracorporeal life support (ECLS) implantation (ECMELLA group)-in-hospital survival was 33%. In the Impella group six patients recovered, six received a long-term VAD and 16 died on device. In the ECMELLA group one patient recovered, three received a long-term VAD and five died. The majority of CentriMag implantations as a right ventricular assist device (RVAD) were necessary after LVAD implantation (n=52); of these patients, 14 recovered, eight received long-term VAD and 30 died. The remaining 17 patients were supported by RVAD due to AMI (n=7); postcardiotomy (n=7); right heart failure after heart transplantation (n=2) and ICMP (n=1). Six of these patients recovered, two required long-term VAD and nine died. Survival after MCS implantation for left as well as right heart failure in cardiogenic shock remains low, but is superior to that of patients without mechanical support. Short-term MCS remains an option of choice if right, left or biventricular support is needed.

Driveline Site Is Not a Predictor of Infection After Ventricular Assist Device Implantation

Driveline infections (DLIs) remain a major source of morbidity for patients requiring long-term ventricular assist device (VAD) support. We aimed to assess whether VAD driveline exit site (DLES) (abdomen versus chest wall) is associated with DLI. All adult patients who underwent insertion of a HeartWare HVAD or HeartMate II (HMII) between 2009 and 2016 were included. Driveline infection was defined as clinical evidence of DLI accompanied by a positive bacterial swab and need for antibiotics. Competing risks analysis was used to assess the association between patient characteristics and DLI. Ninety-two devices (59 HMII) were implanted in 85 patients (72 men; median age 57.4 years) for bridge to transplant or destination therapy. VAD DLES was chest in 28 (30.4%) devices. Median time on VAD support was 347.5 days (IQR 145.5, 757.5), with 28 transplants and 29 deaths (27 on device). DLI occurred in 24 patients (25 devices) at a median of 140 days (IQR 67, 314) from implant. Staphylococcus aureus accounted for 15 infections (60%). Freedom from infection was 72.8% (95% confidence interval [CI] 53.1-78.0%) at 1 year and 41.9% (95% CI 21.1-61.5%) at 3 years. In competing risks regression, abdominal DLES was not predictive of DLI (hazard ratio, HR 1.65 [95% CI 0.63, 4.29]), but body mass index (BMI) >30 kg/m was (HR 2.72 [95% CI 1.25, 5.92]). In conclusion, risk of DLI is high among patients on long-term VAD support, and a nonabdominal DLES does not reduce this risk. The only predictor of DLI in this series was an elevated BMI.

The role of Heart Failure Team in managing Mechanical Circulatory Support in a Swiss low-volume institution.

Outcomes after VAD implantation may be dependent on institutional procedural volume. Specifically, it is claimed that high volumes are associated to better clinical results. This study aims to determine if this procedure is safe even in low-volume center. Single center, retrospective cohort study, including Heart Failure consecutive patients who received long-term VAD from 2007 to 2017. Primary outcome was survival to transplant or ongoing MCS at 1-year. Survival analysis was performed using Kaplan-Meier method. Data concerning 50 adult patients were examined; 35 male (70%), mean age 49+/- 8 years. VAD was implanted as BTT in 48 and DT in 2. Devices implanted were: HeartMate II in 18 (36%), HeartWare in 20 (40%), HeartMate III in 12 (24%). Outcomes were: Death in 16 (32%), heart transplant in 24 (48%), uneventful ongoing support 10 (20%). Data were analysed according to pre and post-heart team creation and 2 groups of 25 patients were identified: 2007-2013 (mean INTERMACS level 3.1) and 2014-2017 (mean INTERMACS level 3.9) showing 1-year survival of 56% and 80% respectively. According to the type of device implanted, 3 groups were identified: HMII = 18 (mean INT. level 2.7), HW=20 (mean INT. level 3.3) and HMIII=12 (mean INT. level 3.7), showing survival of 52%, 78% and 91% respectively. Long term MCS can be implanted at low-volume centers with survival rate not inferior to high volume centers. A Heart team specifically trained in heart failure is probably more important than institutional volume in determining outcomes after VAD implantation.

Diagnosis, medical treatment, and stepwise mechanical circulatory support for fulminat myocarditis.

Fulminant myocarditis is one of the most challenging diseases. We sought to examine the outcomes of our multidisciplinary treatment strategy for fulminant myocarditis. A retrospective review of consecutive 30 patients with fulminant myocarditis was conducted. Of the 30 patients, 25 required mechanical circulatory support (MCS). Percutaneous extracorporeal membrane oxygenation (ECMO) was the first-line therapy to rescue the patients and inserted in 23 of them. The other 2 were implanted with temporary ventricular assist device (t-VAD) with extracorporeal centrifugal pump(s). Sixteen of the ECMO-supported patients were later transitioned to t-VAD. Of the 18 patients who underwent t-VAD support, heart function recovered and the VAD was explanted in 10. Four patients were bridged to long-term VAD and the other 4 died on t-VAD. Two patients were directly bridged to long-term VAD by ECMO. Heart function recovered only with ECMO in 4 patients and 1 died on ECMO. Overall survival rate was 83.3%. The duration of ECMO support significantly correlated with total bilirubin level, which was a significant risk factor for mortality. Pathologically, 7 patients (23.3%) had eosinophilic myocarditis and 1 (3.3%) had giant-cell myocarditis, and all the 8 patients underwent immunosuppressive therapy including steroids. Heart function recovered to normal level in 7 of them (87.5%). Timely conversion from the percutaneous ECMO to the temporary VAD before elevation of total bilirubin level is crucial for improving the clinical outcomes. Endomyocardial biopsy is needed to be done as soon as possible, because immunosuppressive therapy carries promising outcomes in certain etiologies.