Risk stratification of patients listed for heart transplantation while supported with extracorporeal membrane oxygenation

Juan B Ivey-Miranda; Christopher Maulion; Marta Farrero-Torres; Matthew Griffin; Edith L Posada-Martinez; Jeffrey M Testani; Lavanya Bellumkonda

doi:10.1016/j.jtcvs.2021.05.032

Risk stratification of patients listed for heart transplantation while supported with extracorporeal membrane oxygenation

J Thorac Cardiovasc Surg. 2023 Feb;165(2):711-720. doi: 10.1016/j.jtcvs.2021.05.032. Epub 2021 May 29.

Authors

Juan B Ivey-Miranda¹, Christopher Maulion², Marta Farrero-Torres³, Matthew Griffin², Edith L Posada-Martinez⁴, Jeffrey M Testani², Lavanya Bellumkonda⁵

Affiliations

¹ Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn; Department of Heart Failure and Heart Transplantation, Centro Médico Nacional Siglo XXI, Hospital de Cardiología, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
² Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn.
³ Heart Failure and Heart Transplant Unit, Hospital Clínic de Barcelona, Barcelona, Spain.
⁴ Department of Echocardiography, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico.
⁵ Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn. Electronic address: Lavanya.bellumkonda@yale.edu.

PMID: 34167814
DOI: 10.1016/j.jtcvs.2021.05.032

Abstract

Objectives: Extracorporeal membrane oxygenation (ECMO) is used to support patients in severe cardiogenic shock. In the absence of recovery, these patients may need to be listed for heart transplant (HT), which offers the best long-term prognosis. However, posttransplantation mortality is significantly elevated in patients who receive ECMO. The objective of the present study was to describe and risk-stratify different profiles of patients listed for HT supported by ECMO.

Methods: Patients listed for HT in the United Network for Organ Sharing database were analyzed. The primary outcome was 1-year survival and was assessed in patients bridged to transplant with ECMO (ECMO_BTT) and patients who were previously supported on ECMO but had it removed before HT (ECMO_REMOVED).

Results: Among 65,636 adult candidates listed for HT (between 2001 and 2017), 712 were supported on ECMO, 292 of whom (41%) underwent HT (ECMO_BTT, n = 202; ECMO_REMOVED, n = 90). Most of the patients with ECMO_REMOVED were transplanted with a ventricular assist device. In ECMO_BTT, recipient age (each 10-year increase), time on the waitlist (both defined as minor risk factors), need for dialysis, and need for mechanical ventilation (both defined as major risk factors) were independent predictors of mortality. ECMO_REMOVED and ECMO_BTT with no risk factors showed 1-year survival comparable to that in patients who were never supported on ECMO. Compared with patients who were never on ECMO, patients in ECMO_BTT group with minor risk factors, 1 major risk factor, and 2 major risk factors had ~2-, ~5-, and >10-fold greater 1-year mortality, respectively (P < .05).

Conclusions: The HT recipients in the ECMO_REMOVED and ECMO_BTT groups with no risk factors showed similar survival as the HT recipients who were never supported on ECMO. In the ECMO_BTT group, posttransplantation mortality increased significantly with increasing risk factors.

Keywords: heart transplant extra-corporeal membrane oxygenation; prognosis.

MeSH terms

Adult
Extracorporeal Membrane Oxygenation*
Heart Transplantation* / adverse effects
Heart-Assist Devices* / adverse effects
Humans
Renal Dialysis
Retrospective Studies
Risk Assessment
Treatment Outcome