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Updated: Aug 5, 2026
Point-of-Care Ultrasound for Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Without Left Ventricular Venting
Published on: January 17, 2025
Risk Stratification for Patients Bridged to Heart Transplantation on Venoarterial Extracorporeal Membrane Oxygenation
Morgan A Hill1, Zachary W Sollie1, Jennie H Kwon1
1Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC.
Insights
The 2018 heart allocation policy increased veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use for heart transplantation (HT). This study identified key risk factors for 1-year mortality in VA-ECMO bridged HT patients to guide selection.
Area of Science:
- Cardiology
- Transplantation Medicine
- Mechanical Circulatory Support
Background:
- The 2018 heart allocation policy increased veno-arterial extracorporeal membrane oxygenation (VA-ECMO) use as a bridge to heart transplantation (HT).
- Poorer outcomes are known with ECMO bridging, yet no risk stratification tool exists for candidate selection.
- This study aimed to identify risk factors for 1-year mortality after VA-ECMO bridging to HT.
Purpose of the Study:
- To analyze risk factors for 1-year mortality in patients bridged to heart transplantation with VA-ECMO.
- To develop a risk stratification guide for selecting candidates for VA-ECMO support before HT.
- To improve decision-making processes for heart transplant candidates requiring mechanical circulatory support.
Main Methods:
- Utilized the UNOS registry to identify adult patients bridged to HT with VA-ECMO (January 2000 - June 2024).
- Performed univariable and multivariable Cox regression analyses to identify recipient and donor variables associated with 1-year post-HT mortality.
- Employed Kaplan-Meier analysis to compare survival rates stratified by the number of identified risk factors.
Main Results:
- 1,235 VA-ECMO-bridged HT patients were analyzed; 1-year survival was 84.29%.
- Key recipient risk factors for 1-year mortality included older age, elevated creatinine, pre-HT ventilator dependence, high total bilirubin, ischemic cardiomyopathy, and re-transplantation.
- Donor factors included female-to-male sex mismatch and prolonged ischemic times (>3.9 hours).
- One-year survival decreased significantly with an increasing number of risk factors (95.36% for 0 factors to 60.95% for ≥3 factors).
Conclusions:
- Patients bridged to heart transplantation with VA-ECMO experience higher post-transplant mortality.
- Identification of specific recipient and donor risk factors aids in more informed patient selection for VA-ECMO support.
- Patients with two or more risk factors demonstrated less than 87% 1-year survival, necessitating careful consideration for transplant candidacy.
Background:
The 2018 heart allocation policy led to increased use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge to heart transplantation (HT). Despite known poorer outcomes with ECMO bridging, no established risk stratification tool exists to guide candidate selection. This study analyzed risk factors for 1-year mortality following VA-ECMO bridged to HT to provide a risk stratification guide for decision-making.
Methods:
The UNOS registry was used to identify all adults bridged to HT with VA-ECMO from January 2000 to June 2024. Recipient and donor characteristics were analyzed. Univariable and multivariable cox regression analyses were performed to identify recipient and donor variables associated with increased 1-year post-HT mortality. Kaplan-Meier analysis was used to compare survival stratified by the number of risk factors.
Results:
Among 1,235 VA-ECMO-bridged HT patients, unadjusted survival at 30-days, 90-days, 1-year, and 5-years was 93.09%, 89.28%, 84.29%, 72.71%, respectively. Risk factors for increased 1-year mortality included age >61 years (p=0.024), creatinine ≥ 1.4 (p<0.001), ventilator-dependence prior to HT (p<0.001), total bilirubin >3.4 (p<0.001), ischemic cardiomyopathy (p=0.006), and patients undergoing re-transplantation (p<0.001). Donor variables associated with increased risk of 1-year mortality were female-to-male donor-recipient sex mismatch (p=0.003) and ischemic times >3.9 hours (0.035). One-year survival in patients with 0, 1, 2, and ≥ 3 risk factors were 95.36%, 91.12%, 86.10%, and 60.95%, respectively.
Conclusions:
Patients bridged to transplant with VA-ECMO face elevated post-transplant mortality. Identifying key risk factors enables more informed patient selection. Patients with ≥2 risk factors had <87% 1-year survival, warranting cautious consideration for transplant.