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Improvements in Extracorporeal Membrane Oxygenation for Primary Graft Failure After Heart Transplant
Affiliation:1. Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri;2. Division of Cardiology, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri;1. Division of Cardiac Surgery, Northwestern University, Northwestern Medicine, Chicago, Illinois;2. Department of Preventative Medicine, Division of Biostatistics, Northwestern University, Chicago, Illinois;1. Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Massachusetts;2. Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts;3. Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts;4. Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;5. Department of Surgery, Harvard Medical School, Boston, Massachusetts;1. Department of Medicine, Division of Cardiology, University of Minnesota, Minneapolis, Minnesota;2. John and James Kirklin Institute for Research in Surgical Outcomes, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama;3. Department of Medicine, Division of Cardiology, Feinberg School of Medicine Northwestern, Chicago, Illinois;4. Department of Surgery, Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina;5. Department of Medicine, Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah;6. Henry Ford Health System, Detroit, Michigan;7. The Society of Thoracic Surgeons Research Center, The Society of Thoracic Surgeons, Chicago, Illinois;8. Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama;9. Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan;10. Department of Surgery, Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania;1. Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, Florida;2. Medical Department, SpecialtyCare, Inc, Nashville, Tennessee;3. Departments of Surgery and Pediatrics, Children’s Hospital of Georgia, Augusta University, Augusta, Georgia;4. Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia;5. St. Elizabeth Medical Center, Appleton, Wisconsin;6. University of Houston, Houston, Texas;7. HCA Healthcare Research Institute, Nashville, Tennessee;8. University of Arizona, Tucson, Arizona
Abstract:
BackgroundSevere primary graft failure is a life-threatening complication of heart transplantation that may require venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. Surgical practices and management strategies regarding VA-ECMO vary between and within centers.MethodsWe performed a single-center retrospective cohort study on adult patients who received VA-ECMO for primary graft failure between 2013 and 2020. Clinical data were obtained from chart review and national databases. Patients were stratified by transplantation before or after 2017, when our center adopted additional objective criteria for VA-ECMO, adopted partial-flow support, and changed from central cannulation to chimney graft arterial cannulation of brachiocephalic, axillary, or aorta. The primary outcome was survival to device weaning. Secondary outcomes were survival to discharge, survival to 1 year, complications on support, and time to sedation weaning and extubation.ResultsFrom 276 heart transplant recipients, 39 severe primary graft failure patients requiring VA-ECMO were identified. Incidence of graft failure was 13% (n = 18 of 135) pre-2017 and 15% (n = 21 of 141) post-2017. Survival at all time points improved significantly after 2017, with greatest difference in survival to device weaning (61% pre-2017 vs 100% post-2017). After controlling for other factors in multivariable Cox regression modeling, transplantation after 2017 was a predictor of reduced mortality (hazard ratio, 0.209; 95% CI, 0.06-0.71; P = .01). Significant differences were not observed in other secondary outcomes of recovery.ConclusionsThe new VA-ECMO strategy displayed reasonable survival and a remarkable improvement from the prior system.
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