Long-Term Triple Temporary Mechanical Circulatory Support as a Bridge to Triple Organ Transplant

Abstract

Introduction Temporary mechanical circulatory support (MCS) systems such as the intra-aortic balloon pump (IABP), Impella, and extracorporeal membrane oxygenation (ECMO) are used to stabilize decompensating patients with cardiogenic shock with the strategy of either durable MCS and/or transplantation. We present the use of all three temporary MCS platforms in a single patient as a bridge to triple organ—heart-liver-kidney transplantation. Case Report The patient is a 51-year-old gentleman with history of atrioventricular canal repair, inotrope-dependent heart failure, non-sustained ventricular tachycardia, chronic kidney disease stage III, and cirrhosis who failed outpatient inotrope therapy. His tachyarrhythmias, and liver and renal disease made him a poor candidate for durable MCS. He underwent initiation of axillary IABP and was listed as UNOS Status 2 for a heart-liver-kidney transplant. This platform supported the patient for 13 days, however, due to persistently elevated pulmonary artery pressures and poor left ventricular unloading we upgraded our support platform to the axillary Impella 5.5 (achieving >4.5lpm for 78 days). During this time frame, he was transitioned to UNOS Status 7 twice, once for heparin-induced thrombocytopenia where we were required to modify our anticoagulation to include Argatroban, and then separately when he became septic and the Impella was explanted. Still requiring circulatory support, we advanced to femoral cannulation VA ECMO. After four days on VA ECMO support as a UNOS Status 1, the patient received an en-bloc heart and liver, which was followed by a kidney implant the next day. Myocardial biopsies have consistently showed ISHLT Grade 0 R rejection, and hemodynamics showed cardiac index of 2.7 L/min/m2 and normal biventricular pressures. His postoperative stay was uncomplicated, and he was discharged to inpatient rehab after 38 days post-transplantation. Summary Temporary MCS platforms can provide varying levels of support, and implementation should be balanced by their inherent risks. This case displayed the utilization of three temporary MCS platforms in a single patient, and to our knowledge is the longest documented support for an Impella 5.5 (78 days Impella, 95 days total MCS support) to successfully bridge to heart-liver-kidney transplantation.