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Use of extracorporeal membrane oxygenation for heart graft dysfunction in adults: incidence, risk factors and
Pierre-Emmanuel Noly, Mélanie Hébert, Yoan Lamarche
1From the Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, Que. (Noly, Hébert, Lamarche, Carrier); the Department of Cardiac Surgery, Quebec Heart and Lung Institute, Université Laval, Québec, Que. (Cortes, Voisine); and the Department of Thoracic and Cardiovascular Surgery, Rennes Hospital, University of Rennes 1, Rennes, France (Mauduit, Verhoye, Flécher).
Insights
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) use for cardiac graft dysfunction after heart transplantation is increasing but difficult to predict. While survival is lower with VA-ECMO, delayed use and bleeding increase in-hospital mortality.
Area of Science:
- Cardiology
- Transplantation Medicine
- Critical Care Medicine
Background:
- Cardiac graft dysfunction (GD) following heart transplantation (HT) presents a significant clinical challenge.
- Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a potential but complex treatment option for severe GD.
- Current decisions regarding VA-ECMO use are often experience-based and lack standardized predictive factors.
Purpose of the Study:
- To determine the incidence of VA-ECMO use in patients with GD post-HT.
- To evaluate the early and long-term outcomes of GD patients treated with and without VA-ECMO.
- To identify risk factors associated with the need for VA-ECMO and early mortality.
Main Methods:
- A retrospective analysis of adult patients undergoing HT across three centers over a 10-year period.
- Inclusion criteria: adherence to the International Society for Heart and Lung Transplantation definition of GD.
- Comparison of pre-transplant, intraoperative, and post-transplant characteristics between GD patients with and without VA-ECMO support.
Main Results:
- Out of 135 GD patients, 66 received VA-ECMO and 69 did not; GD and VA-ECMO incidence rose over time.
- No pre-transplant predictors for VA-ECMO were identified; however, VA-ECMO patients had higher lactate and inotrope requirements post-HT.
- Five-year survival rates were 78% for medical treatment vs. 40% for VA-ECMO; delayed VA-ECMO initiation and bleeding correlated with higher in-hospital mortality.
Conclusions:
- The incidence of GD and the need for VA-ECMO post-HT are increasing and remain difficult to predict.
- While in-hospital mortality has decreased, it remains high for VA-ECMO patients, particularly with delayed initiation.
- Optimizing the timing of VA-ECMO and managing postoperative bleeding are critical for improving outcomes in these high-risk patients.
Background:
The decision about whether to use venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiac graft dysfunction (GD) is usually made on a case-by-case basis and is guided by the team's experience. We aimed to determine the incidence of VA-ECMO use after heart transplantation (HT), to assess early- and long-term outcomes and to assess risk factors for the need for VA-ECMO and early mortality in these patients.
Methods:
We included adults who underwent heart transplantation at 3 cardiac centres who met the most recent International Society for Heart and Lung Transplantation definition of graft dysfunction (GD) over a 10-year period. Pre-transplant, intraoperative and posttransplant characteristics of the heart recipients as well as donor characteristics were analyzed and compared among recipients with GD treated with and without VA-ECMO.
Results:
There were 135 patients with GD in this study, of whom 66 were treated with VA-ECMO and 69 were not. The mean follow-up averaged 81.2 months (standard deviation 36 mo, range 0-184 mo); follow-up was complete in 100% of patients. The overall incidence of GD (30%) and of VA-ECMO use increased over the study period. We did not identify any predictive pre-transplantation factors for VA-ECMO use, but patients who required VA-ECMO had higher serum lactate levels and higher inotropes doses after HT. The overall survival rates were 83% and 42% at 1 year and 78% and 40% at 5 years among patients who received only medical treatment and those who received VA-ECMO, respectively. Delayed initiation of VA-ECMO and postoperative bleeding were strongly associated with increased in-hospital mortality.
Conclusion:
The incidence of GD increased over the study period, and the need for VA-ECMO among patients with GD remains difficult to predict. In-hospital mortality decreased over time but remained high among patients who required VA-ECMO, especially among patients with delayed initiation of VA-ECMO.
