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Different Clinical Course and Complications in Interagency Registry for Mechanically Assisted Circulatory Support 1 (INTERMACS) Patients Managed With or Without Extracorporeal Membrane Oxygenation

Han, Jason, J.*; Chung, Jennifer*; Chen, Carol, W.*; Gaffey, Ann, C.*; Sotolongo, Alex; Justice, Christyna*; Ameer, Alyse, E.*; Rame, J., Eduardo; Bermudez, Christian*; Acker, Michael, A.*; Atluri, Pavan*

doi: 10.1097/MAT.0000000000000674
Adult Circulatory Support

Extracorporeal membrane oxygenation (ECMO) as a bridge to left ventricular assist device (LVAD) implantation has shown promise in improving end-organ function and optimizing outcomes in some critically ill patients, but the practice remains controversial. Retrospective review of patients who received LVADs from May 2008 to September 2016 at a high-volume, tertiary care cardiovascular center was performed. Subjects were Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) class 1 patients divided into ECMO bridge and non-ECMO bridge cohorts. Patient demographics, adverse events, and survival at immediate and 1 year postoperative time points were compared between groups. In total, 235 patients received a HeartMate II or HVAD during the study period. Among INTERMACS 1 patients, 18 were ECMO bridge and 17 were non-ECMO bridge. Age, gender and bridge-to-transplant proportions (50% vs. 53%) were similar between groups. The ECMO bridge group had lower hemoglobin (7.9 ± 1.1 vs. 10.2 ± 2.2; p < 0.01), platelet (101 [70] vs. 176 [115]; p < 0.05), and prealbumin levels (10.6 ± 4.3 vs. 17.3 ± 7.7; p < 0.01). Nearly half (n = 8; 44%) of the ECMO bridge patients required packed red blood cell transfusions before VAD and were more likely to be on an epinephrine drip (78% vs. 12%; p < 0.01). However, along with these adjunctive measures, the ECMO bridge did effectively improve hemodynamic profiles by the time of VAD implant resulting in lower central venous pressure (7.7 ± 2.5 vs. 10.4 ± 4.8; p < 0.01) and mean pulmonary arterial pressure (18 ± 9 vs. 32 ± 8; p < 0.01). It also allowed for restoration of end-organ function as noted by comparable creatinine (1.0 [1.2] vs. 1.4 [0.6]) and total bilirubin levels (1.6 ± 1 vs.1.5 ± 1.7) between the two groups. There was no difference in rates of adverse events. Survival at 30 days postoperative and at 1 year (77% vs. 88%; p = 0.6) was similar. This study demonstrates that ECMO bridge is a central component of a multifaceted strategy for stabilization of select patients with severe hemodynamic instability before LVAD implantation. Further studies to optimize patient selection should be further explored.

From the *Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania

Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut

Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Submitted for consideration January 2017; accepted for publication in revised form August 2017.

Presented at the annual International Society of Heart and Lung Transplantation Conference; April 5, 2017, San Diego.

Disclosure: Dr. Michael Acker is a consultant for Thoratec Corp. Dr. Pavan Atluri is a principal investigator for ENDURANCE, MOMENTUM III, and LATERAL Clinical Trials. The remaining authors have no conflicts of interest to report.

Correspondence: Jason Han, MD, Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Copyright © 2018 by the American Society for Artificial Internal Organs