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

 

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Objectives: The implantation of durable ventricular assist devices (VAD) in patients on venoarterial membrane oxygenation (VA-ECMO) is controversial. Available studies in this field are limited to anecdotal case reports. In this study, data of 10 high volume VA-ECMO/VAD centers are collected and analyzed.

Methods: Following approval from corresponding ethic committees, data of patients undergoing durable mechanical circulatory support implantations at 10 institutions between January 2010 and July 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 VAD implantation surgery are collected and analyzed. The primary end point was survival or cardiac transplantation at 1 year.

Results: A total of 494 patients met the inclusion criteria. The average age was 53 ± 12 years. A majority of the patients (82%) were male and up to 58% of the patients had ischemic cardiomyopathy. The VA-ECMO cannulation was peripheral in 88 and 33% of the patients had cardiopulmonary resuscitation 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 and 26% of the patients had intra-aortic balloon pump in addition of VA-ECMO. Cardiopulmonary bypass was used in 63% of the patients at the time of VAD implantation. 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 were 75, 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 with elective VAD implantations. Nevertheless, considering preoperative characteristics of these patients, acceptable outcome of 50% 1 year success was achieved.