Related Experiment Video
Updated: Aug 22, 2025
Point-of-Care Ultrasound for Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Without Left Ventricular Venting
Published on: January 17, 2025
Lack of volume-outcome association in ECMO bridge to heart transplantation
William G Cohen1, Jason Han2, Max Shin1
1Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Insights
Low-volume centers can successfully use veno-arterial extracorporeal membrane oxygenation (VA-ECMO) to bridge patients to heart transplantation, achieving outcomes comparable to high-volume centers. This finding supports the use of VA-ECMO across different transplant center volumes.
Area of Science:
- Cardiology
- Transplantation Medicine
- Mechanical Circulatory Support
Background:
- Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a critical bridge to cardiac transplantation.
- The 2018 United Network for Organ Sharing (UNOS) policy change impacted waitlist status for patients on mechanical circulatory support (MCS).
- Center volume may influence VA-ECMO support duration and posttransplant outcomes.
Purpose of the Study:
- To investigate the association between a heart transplant center's annual volume and VA-ECMO support duration.
- To evaluate the impact of center volume on posttransplant outcomes for patients supported with VA-ECMO.
- To compare outcomes between high-volume centers (HVCs) and low-volume centers (LVCs) in the context of VA-ECMO bridge to transplant.
Main Methods:
- Analysis of adult heart transplant candidates listed between January 1, 2011, and December 31, 2021, using the UNOS database.
- Stratification of centers into high-volume (≥20 transplants/year) and low-volume (<20 transplants/year).
- Comparison of VA-ECMO support duration, transplant rates, waitlist mortality, and posttransplant survival between HVCs and LVCs.
Main Results:
- Patients at HVCs were more likely to receive intra-aortic balloon pump and inotrope support at listing.
- VA-ECMO support duration was shorter at HVCs (6 days) compared to LVCs (8 days).
- No significant differences were observed in transplant rates, waitlist mortality, delisting, recovery, or posttransplant survival between HVCs and LVCs.
Conclusions:
- Low-volume centers demonstrate the capability to effectively utilize VA-ECMO for bridging patients to heart transplantation.
- Outcomes for patients bridged with VA-ECMO are comparable between high-volume and low-volume centers.
- These findings suggest that VA-ECMO can be a successful bridge to transplant regardless of center volume.
Background:
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a bridge to cardiac transplantation. As the 2018 United Network for Organ Sharing (UNOS) heart allocation policy change elevated waitlist status for patients receiving mechanical circulatory support (MCS), we aimed to determine if a center's annual heart transplant volume was associated with ECMO-support duration and posttransplant outcomes.
Methods:
Adults heart transplant candidates between January 1, 2011, and December 31, 2021, were isolated in the UNOS database. VA-ECMO use was identified at the time of listing for transplant. Average annual transplant volume was calculated by the center, with stratification as high (≥20 cardiac transplants, high volume center [HVC]) or low (<20 cardiac transplants, low volume center [LVC]) volume centers. Results are reported as mean (interquartile range) or n (%).
Results:
In total, 543 patients at HVCs and 275 at LVCs were listed for transplant supported with VA-ECMO. Those listed at HVCs were more likely to be supported by intra-aortic balloon pump (103 [19%] vs. 32 [11.6%], p = .008) and inotropes (267 [49.2%] vs. 106 [38.5%], p = .004) at time of listing. Patients at HVCs received ECMO support for 6 [4-9] days, compared to 8 [4-15] days at low-volume centers (p = .030), and but were cannulated a similar time before listing (2 [1-5] vs. 3 [1-7] days, p = .517). There were no differences in rates of transplant (p = .2126), waitlist mortality (p = .8645), delisting due to clinical deterioration (p = .8419), or recovery (p = .1773) between groups. Among transplanted patients, there were no differences in support duration (6 [4-8] vs. 6 [4-10], p = .187), or time from registration to transplant (5 [2-20] vs. 7 [3-22] days, p = .560). Posttransplant survival did not vary (p = .293).
Conclusions:
LVCs can successfully bridge patients to transplant with VA-ECMO and achieve comparable outcomes to HVCs.
