Temporary mechanical circulatory support: insights and evolving strategies

Abstract

Purpose: The goal of this study is to evaluate the utilization and outcomes of temporary mechanical circulatory support (MCS) among patients listed for cardiac transplantation (CT). There is a constant threat of sudden clinical deterioration in these patients that could necessitate emergent MCS. All advanced heart failure and transplant centers in India are plagued by issues of late referrals, low organ donation rates, and financial constraints. Here, we share our experience and explain our evolving strategies tailored to improve outcomes.

Methods: Single-center retrospective analysis of temporary MCS implanted in patients listed for CT from January 1, 2015, to December 31, 2019.

Results: A total of 35 patients had 41 MCS implantations. Twenty-four cases were pre-transplant and 11 cases were post-transplant. Veno-arterial extracorporeal membrane oxygenator was the most commonly (20 cases, 44.4%) used MCS modality. Primary outcome of in-hospital mortality was noted in 17 patients (48.5%) in this high-risk profile. All but 2 of the 12 patients that underwent pre-transplant MCS, and were bridged to cardiac transplant, survived the index hospitalization accounting for 90% survival in this subset of patients. The secondary outcome of MCS-related vascular injury was observed in 9 patients (25.7%).

Conclusion: This single-center observational study demonstrates that early planning and timely institution of MCS improves outcomes in high-risk MCS patients bridged to cardiac transplant. The incidence of MCS-related vascular complications can be improved with development of standard operating protocols.

Keywords: Extracorporeal membrane oxygenation; Heart failure; Heart transplant; Left ventricular assist device; Mechanical circulatory support.

Fig. 1

Koji-VAD cannulation via lateral thoracotomy in a non-ischemic cardiomyopathy patient with severe acute biventricular failure (INTERMACS 1 profile): 1, axillary artery outflow cannula; 2, left ventricular apical inflow cannula; 3, Romovac® suction drain; 4, femoral venous inflow cannula; 5, intra-aortic balloon pump; 6, left femoral venous sheath for temporary pacing; 7, tube clamp on the LV cannula to regulate left ventricular unloading; 8, Y-connector joining the 2 inflow cannulae to the CentriMag® pump

Fig. 2

Stratification of the total cohort of 35 patients according to INTERMACS profile at the time of first presentation

Fig. 3

Outcomes-based on INTERMACS profile at the time of admission

Fig. 4

Year-wise mechanical circulatory support (MCS) and related mortality

Fig. 5

Survival of mechanical circulatory support (MCS) bridged to transplant vs. no transplant

Fig. 6

Demonstrating modality, device, cannulation site, which device, and when. eCPR, extracorporeal membrane oxygenator during cardiopulmonary resuscitation; RV, right ventricle; LV, left ventricle; ECMO, extracorporeal membrane oxygenator; PVR, pulmonary vascular resistance; VAD, ventricular assist device; LVAD, left ventricular assist device