Extracorporeal Membrane Oxygenation for Primary Graft Failure Following Heart Transplantation

Abstract

Purpose Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy providing hemodynamic support to patients with advanced cardiorespiratory compromise. Following orthotopic heart transplantation (HTX), primary graft failure (PGF), especially wherein there is significant right ventricular dysfunction, can necessitate such intensive support to bridge to recovery or additional therapy. Marginal donors are used to increase the donor pool given the excess of candidates in most jurisdictions. Methods We conducted a single-center retrospective cohort study examining HTX from donation after brain death (DBD) donors that required post-operative ECMO for PGF from January 2008 - September 2020. Donor and recipient information were collected including demographics, renal function, echocardiographic measurements, biopsy data, and outcome measures. Marginal donor hearts were identified according to validated criteria including use of donor triiodothyronine (T3), donor left ventricular ejection fraction 60 years old, and donor ischemic time >6 hours or >4 hours if donor age >40 years old. Results Overall, 376 DBD HTX were performed, of which 126 involved marginal donor hearts (33.3%). ECMO was required in 81 (21.4%) of these patients, 42 (51.9%) of which involved marginal donor hearts. Thus, ECMO rates were 15.5% and 33.3% in non-marginal and marginal donor hearts, respectively. Overall, ECMO was successfully weaned in 75 (92.6%) and 62 (76.5%) survived their index HTX admission. Among patients who received non-marginal organs, 36 (92.3%) had ECMO weaned and 31 (79.5%) survived their index HTX admission versus 39 (92.9%) and 31 (73.8%) for these endpoints respectively among patients receiving marginal organs. Conclusion Our center s experience indicates that ECMO can provide satisfactory outcomes in HTX patients requiring advanced hemodynamic support post-operatively for PGF. Marginal donor hearts were more likely to require ECMO support post-operatively but had comparable and acceptable rates of index-admission survival compared to non-marginal cases. Further work is needed to evaluate outcome differences as efforts are made to expand the donor pool around the world.