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Venoarterial Extracorporeal Membrane Oxygenation
Support as a Bridge to Heart Transplant: Report of 3 Cases
Ender Gedik,1 Aydın Ulaş,1 Özgür Ersoy,2 Funda Atar,1 Aynur Camkıran Fırat,1
Arash Pirat1
Abstract
Introduction
Heart transplant is the only definitive treatment of
end-stage heart failure. Venoarterial extracorporeal
membrane oxygenation may be used as a bridge to
heart transplant. Among 31 patients who underwent
heart transplant between January 2014 and June
2016, we present our experiences with 3 patients who
received venoarterial extracorporeal support as a
bridge to heart transplant. The first patient was a
51-year-old male with ischemic dilated cardiomyopathy. Transplant was performed after 6 days of
extracorporeal support, and the patient was discharged and alive at follow-up. Patient 2 was a 12-yearold girl with dilated cardiomyopathy who presented
with cardiac arrest. Extracorporeal support was
initiated during cardiopulmonary resuscitation. She
had full neurologic recovery and remained on the
wait list. She received a transplant 22 days after
resuscitation. She survived and was alive at day 220
posttransplant. The third patient was a 50-year-old
male with ischemic dilated cardiomyopathy requiring
venoarterial extracorporeal support. Percutaneous
balloon atrial septostomy was performed for left
ventricle venting. He underwent transplant on day 28
after intensive care unit admission. He died 29 days
after release from the hospital. Regarding patients on
heart transplant wait lists who are worsening despite
optimal medical therapy, venoarterial extracorporeal
membrane oxygenation support is a safe and viable
last resort.
Heart transplant is the only definitive treatment of
end-stage heart failure for pediatric and adult
patients.1,2 Venoarterial extracorporeal membrane
oxygenation (VA-ECMO) is one of several
mechanical circulatory support devices used for
patients with refractory cardiac failure (RCF). The
advantages of ECMO over other percutaneous
devices are its ease of insertion and its ability to
support right, left, or biventricular failure at high
blood flows.3 This technique may be used as a bridge
to heart transplant in both pediatric and adult
patients.2,4 Venoarterial extracorporeal membrane
oxygenation is increasingly used as a short-term
circulatory support in patients with RCF, providing a
bridge to heart transplant.5 We present our
experience with 3 patients who received VA-ECMO
as a bridge to emergency heart transplant in the
intensive care unit (ICU).
Key words: Cardiac failure, Extracorporeal assist,
Preoperative and transplant
From the 1Department of Anesthesiology and Critical Care Medicine and the 2Department of
Cardiovascular Surgery, Faculty of Medicine, Baskent University Ankara, Turkey
Acknowledgements: The authors declare that they have no sources of funding for this study,
and they have no conflicts of interest to declare.
Corresponding author: Ender Gedik, Baskent University Faculty of Medicine, Department of
Anesthesiology and Critical Care Medicine, 06490 Ankara, Turkey
Phone: +90 312 203 6868 (extension 4841) E-mail: [email protected]
Experimental and Clinical Transplantation (2016) Suppl 3: 121-124
Copyright © Başkent University 2016
Printed in Turkey. All Rights Reserved.
Case Reports
We retrospectively screened the data of 31 heart
transplants performed between January 2014 and
June 2016 at our center. Among these were patients
who were admitted to the ICU before heart
transplant who did not respond to optimal medical
therapy and required VA-ECMO for circulatory
support.
Case 1
A 51-year-old male patient with ischemic biventricular
dilated cardiomyopathy was admitted to the ICU for
RCF. His RCF did not improve with pharmacologic
therapies, and VA-ECMO support was initiated.
Right femoral vein and left femoral artery
cannulations with a leg perfusion cannula were
performed percutaneously. Heart transplant was
DOI: 10.6002/ect.tondtdtd2016.P52
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Ender Gedik et al/Experimental and Clinical Transplantation (2016) Suppl 3: 121-124
performed after 6 days on VA-ECMO support.
Duration of surgery was 7 hours. There was no need
for extracorporeal support during the postoperative
period. He was discharged from the ICU on
postoperative day 12 and hospital on postoperative
day 19. At follow-up, the patient was alive on
posttransplant day 307.
Case 2
A 12-year-old girl with biventricular dilated
cardiomyopathy of unknown cause was admitted to
the ICU because of no response to medical therapy
and worsening heart failure. She had a cardiac arrest
10 days after ICU admission. Venoarterial extracorporeal membrane oxygenation was initiated
during cardiopulmonary resuscitation (CPR). Left
femoral vein and right femoral artery with leg
perfusion cannulas were inserted percutaneously.
She had full neurologic recovery and remained on
the heart transplant wait list. Peripheral VA-ECMO
was continued for 15 days. However, she had lower
leg ischemia on day 25 after admission. Peripheral
VA-ECMO support was converted to central VAECMO and continued for 7 days. The patient
received a heart transplant on day 32 in the ICU and
did not require ECMO support postoperatively.
Duration of surgery was 7 hours. Her ECMO-related
complications were lower limb ischemia without
major sequels, amputation of 3 fingertips due to
thrombosis of digital arteries from the arterial
cannula, and bleeding during central VA-ECMO. She
was discharged from the ICU on day 66. The patient
was alive on posttransplant day 220.
Case 3
A 50-year-old male patient with ischemic biventricular dilated cardiomyopathy was admitted to the
ICU for worsening heart failure symptoms despite
medical treatment. Although he initially improved
with optimal pharmacologic therapy, he developed
cardiogenic shock 5 days after ICU admission, and
VA-ECMO was commenced. Left femoral vein and
right femoral artery with leg perfusion cannulae
were used for vascular access. Percutaneous balloon
atrial septostomy was performed for left ventricle
venting. Peripheral VA-ECMO support was continued
for 23 days. He underwent heart transplant on day 28
of ICU admission. Duration of surgery was 9 hours.
There was no need for extracorporeal support during
the postoperative period. He was discharged from
Exp Clin Transplant
the ICU on postoperative day 42 and hospital on
postoperative day 49. He died 29 days after release
from hospital at home (postoperative day 78).
Discussion
In this report, we present our experiences with 3
patients who received VA-ECMO as a bridge to heart
transplant in the ICU. All patients were treated in our
ICU during the perioperative period. All patients
were on the wait list of the National Organ
Procurement Organization Registry as candidates for
emergency heart transplant after VA-ECMO support.
All peripheral VA-ECMOs were done with percutaneous cannulation using ultrasonography guidance.
Venoarterial extracorporeal membrane oxygenation
was performed under analgesia and sedation with
local anesthesia for patients 1 and 3. Patient 2 was
intubated during the procedure because of cardiac
arrest. All patients were discharged from the hospital
with no major long-term complications, except for
patient 2 who received ECMO support. Patients 1
and 2 are still alive and periodically supervised by
our center. Patient 3 died 29 days after discharge
from hospital at home.
Venoarterial extracorporeal membrane oxygenation represents an effective therapy for RCF and
cardiac arrest. It is used in RCF patients as a bridge to
decision, a bridge to candidacy, and a bridge to heart
transplant. Its routine use for urgent heart transplant
is not widely accepted in most transplant centers
because of limited duration for this support.6 In our
country, a heart allocation system provides priority
status granted to the sickest patients. This system is
similar to some European countries and the United
States.5 In our report, all 3 patients were admitted to
our ICU for medical treatment. None of them were
on the national wait list. All patients showed no
improvements despite optimal medical therapy with
advanced hemodynamic monitoring. Our team
decided to perform VA-ECMO as a salvage therapy.
Patient 2 had cardiac arrest and required
extracorporeal CPR . We enrolled all 3 patients to our
heart allocation system after VA-ECMO support and
considered these patients as urgent candidates for
heart transplant, giving them high priority.
Extracorporeal membrane oxygenation cannulation has traditionally been performed by cardiothoracic surgeons in the operating room with
open access. They use both peripheral and central
Ender Gedik et al/Experimental and Clinical Transplantation (2016) Suppl 3: 121-124
approaches. Recently, other specialists (anesthesiologists and intensivists) have performed cannulation
by a percutaneous approach guided with USG in the
ICU. The most frequently used cannulation site is the
femoral vessel.4 Barth and associates reported
their experience on 242 patients with emergent
venoarterial extracorporeal life support. They used
femoral veins for cannulation. They also stated that
femoral cannulation provided reliable access in
emergency conditions.6 The femoral route was used
in our patients for VA-ECMO support at the bedside.
Peripheral VA-ECMO support can be used as a
bridge to urgent heart transplant. In a large cohort of
242 patients, 8 underwent urgent heart transplant.
The mean duration of extracorporeal life support was
6.3 ± 4.6 days.6 In our investigation of 31 heart
transplant procedures, 3 patients underwent urgent
heart transplant. The mean duration of VA-ECMO
support was 17.0 ± 9.5 days (range, 6-23 d) in our
patients.
Pediatric patients awaiting transplant frequently
require bridge to heart transplant with mechanical
circulatory support. In a recent large analysis of 2777
pediatric heart transplant patients, 617 (22%) had
mechanical circulatory support, with 189 (30%)
receiving VA-ECMO support.2 Similar to this report,
patient 2, who was a 12-year-old girl, required
VA-ECMO support when she underwent emergency
heart transplant. Because of ischemic complications,
peripheral and central types of VA-ECMO support
were used for this patient.
Lasa and associates studied the effectiveness of
extracorporeal CPR after failed conventional CPR in
pediatric patients. They concluded that for children
who receive in-hospital CPR for more than 10
minutes, extracorporeal CPR was associated with
improved survival with favorable neurologic results
compared with conventional CPR.7 Despite better
prognosis with this type of extracorporeal support,
there have been few reports regarding urgent heart
transplant after extracorporeal CPR.8 We used VAECMO support during CPR for our pediatric patient
(patient 2) because heart failure, and she underwent
emergency heart transplant after 22 days.
Extracorporeal mechanical circulatory support
has several complications. First, the ECMO circuit
activates the coagulation, fibrinolytic, and complement systems. The activation of these pathways
results in both bleeding and thrombotic complications.
Bleeding is the most common complication of
123
extracorporeal support. During treatment of
anticoagulation, the risk of bleeding must be
balanced with the risk of thrombosis. Thrombosis can
occur in any part of the ECMO circuit.8 All 3 patients
received anticoagulation agents with intravenous
unfractionated heparin infusion. Anticoagulation
administration was monitored with activated
clotting time at the bedside. The targeted level of
activated clotting time was 180 seconds. There were
no bleeding and thrombotic complications in patients
1 and 3. Patient 2 had thrombosis of digital arteries
during peripheral ECMO support and bleeding
during central extracorporeal support. We were able
to treat these complications, with no major long-term
effects except for amputation of 3 fingertips.
Left ventricular distension during VA-ECMO can
have several potential complications. Increased
myocardial wall stress and oxygen demand due to
increased end-diastolic volume and reduced
coronary perfusion pressure can result in impaired
ventricular recovery or worsening of injury. To
evaluate adequate left ventricular decompression,
echocardiography can be helpful.8 When pharmacologic measures are not able to provide adequate
decompression, some mechanical techniques like left
ventricular venting, atrial septostomy, and additional
mechanical support devices can be considered.4,8
Patient 3 had left ventricular distention during
extracorporeal support. This complication was
treated by balloon atrial septostomy at the coronary
angiography unit.
Peripheral cannulation of femoral vessels is
associated with increased risk of limb ischemia. In
cases with femoral artery cannulation, this risk can
be remedied with insertion of a distal perfusion or
drainage cannula to provide antegrade arterial
perfusion.8 In our 3 patients, a distal perfusion
cannula with anterograde route was inserted before
femoral arterial ECMO cannulation. Patients were
examined daily with Doppler ultrasonography for
adequate arterial circulation in the arterial side.
Despite these measures, patient 2 developed limb
ischemia. This complication was treated with
decannulation and conversion to central VA-ECMO.
In a large series, temporary or short-term
mechanical circulatory support before heart
transplant as a preoperative bridging have been
reported to have comparable or good postoperative
outcomes compared with VA-ECMO.9,10 We have
limited experience regarding extracorporeal support
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for bridge to urgent heart transplant. However, our
patients were successfully transplanted after support
with VA-ECMO. We had no inpatient mortality.
In conclusion, for patients on heart transplant
wait lists who are worsening despite optimal medical
treatment, VA-ECMO support is a safe and viable last
resort.
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