An Analysis of Cardiac Amyloidosis Patients in Cardiogenic Shock Bridged with Temporary Mechanical Circulatory Support to Durable Left Ventricular Assist Device and Heart Transplant

Abstract

Purpose Limited data exists on the use of temporary mechanical circulatory support (TMCS) in end-stage cardiac amyloidosis (CA) patients. This study aims to describe the CA patients in cardiogenic shock (CS) who were bridged with TMCS to durable left ventricular assist device (LVAD) or orthotopic heart transplant (OHT). Methods Data on demographics, TMCS, pre-implant Echo and clinical outcomes were retrospectively analyzed in 34 CA patients with ≥30-day survival post-LVAD or OHT at our institutions from 01/2008-10/2020. Descriptive statistics are reported. Results 17 CA patients (mean age 62 ± 7 years, 47% Caucasian, 82% male) were bridged to LVAD (75% centrifugal, 75% destination therapy) or OHT (47% under new heart allocation system) with TMCS (Table 1). 15 had intra-aortic balloon pump (IABP) support, and 3 required veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for median 11 [5, 20] and 7.5 [7.3, 7.5] days, respectively. Most patients with TMCS had SCAI stage C (18%) and D (82%) CS, whereas those without TMCS had stage B (9%) and C (42%) CS. More patients with vs without TMCS used ≥2 vasoactive agents (65% vs 18%, p=0.0045), were intubated (18% vs 6%, p=0.14), and had a dilated right ventricle (59% vs 29%, p=0.04), respectively. The median survival in patients with vs without TMCS was 17 [11, 48] vs 43 [16, 57] months (p=0.0008), respectively. Conclusion Select CA patients with more severe CS (stage C/D) can be bridged with IABP and VA-ECMO (rescue therapy), whereas those with less severe CS (stage B/C) can be stabilized with medical therapy to LVAD or OHT. Nearly half of the OHT occurred under the new heart allocation system. Future studies are warranted to evaluate optimal patient selection and safety of bridging these high-risk patients to a desired clinical outcome, especially if such patients present in extremis (stage E CS).