Bridging to cardiac transplantation with circulatory support devices
Several devices are currently available for bridging to cardiac transplantation, but the efficacy of each has not been established. From September 1983 to March 1990, we supported 26 transplant candidates with 27 mechanical assist devices. One patient was supported twice and transplanted twice. Extracorporeal membrane oxygenation (ECMO) was used to bridge 2 patients; external ventricular assist devices (VAD’s), 16 patients; internal left ventricular assist system (LVAS), 6 patients; and implantable prosthetic replacement ventricles (TAH), 2 patients. The 20 men and 6 women, aged 12 to 63 years (mean 41 years), suffered cardiogenic shock due to ischemic (15 patients), postpartal (3 patients), idiopathic (5 patients), congenital (1 patient), post transplant rejection (1 patient), and drug-induced (1 patient) cardiomyopathy. Seven patients with isolated left ventricular failure (LVF) received only left ventricular assist devices (LVAD’s); five patients with severe LVF and moderate right ventricular failure (RVF) received LVAS; while 14 patients with severe biventricular failure received LVAS (1 patient), ECMO (2 patients), biventricular assist devices (BVAD’s; 9 patients), and TAH (2 patients). Patients were supported for periods of 0.5–440 days (mean 58) with mean flows of 2.15–2.801/min per m2. Fifteen patients were transplanted (12 of whom were discharged) and 10 patients died without transplants. One patient remains on LVAS support awaiting transplantation. The two ECMO patients died at one and 30 days post transplant, due in part to ECMO complications. Ten patients were denied transplants because of renal failure (8 patients), infection (9 patients), bleeding (8 patients), and cerebrovascular accident (CVA) (3 patients). The 12 survivors were supported with VAD’s (9 patients) or LVAS (3 patients). Three had driveline infections, 2 had bleeding complications, 1 developed mediastinitis post transplant, and 1 had a CVA from a mechanical failure. One died of rejection six months later, while 11 are well 6–58 months (mean 27 months) post transplant.
These data suggest that prolonged ECMO is inadequate for bridging. Patients with isolated LVF do well with LVAD or LVAS; those with biventricular failure usually require BVAD or TAH. Patients may be supported on mechanical devices for up to 440 days, but complications are common. If bridged patients do not meet strict transplant criteria, they must be rejected. If the type of ventricular failrue is appropriately managed, the success of transplantation after mechanical support is more dependent upon patient selection than choice of device.
KeywordsExtracorporeal Membrane Oxygenation Ventricular Assist Device Post Transplant Mechanical Circulatory Support Donor Heart
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