Successful Application of Extracorporeal Membrane Oxygenation as a bridge for Left Ventricular Assist Device Implantation: A Case Series

INTRODUCTION. Left ventricular assist device (LVAD) implantation is indicated in patients with end-stage heart failure. Nonetheless, outcomes after LVAD implantation in the acute setting are poor. For these patients, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a valuable option for providing emergent circulatory support to achieve hemodynamic stability and resolving multiorgan failure. The current literature regarding the application of VA-ECMO as a bridge to LVAD implantation is very limited. Here we report our initial experience in utilizing VA-ECMO as rescue procedure and bridge to LVAD implantation in this patients` population.

METHODS. All patients on VA-ECMO for cardiogenic shock prior to LVAD implantation (n=4) during 2019 were retrospectively analyzed after we prospectively collected baseline patient characteristics, pre-operative treatment and postoperative outcome data.

RESULTS. The patient`s ages were 29, 31, 61, 63. In three patients, the etiology was ischemic heart disease (including one case of post-partum spontaneous coronary artery dissection, and another of cannabis-induced cardiomyopathy). VA-ECMO duration was 144 hours (96-168). LVAD implantation was performed after serial echocardiograms demonstrated no recovery of cardiac function. Duration of hospitalization after the implantation was between 3-9 weeks. All four patients suffered post-operative hemorrhage necessitating re-exploration within the first postoperative day. Both younger patients were discharged home after an unremarkable courses of hospitalization. Our two older patients had a more complicated hospital course punctuated by ventilator dependent respiratory failure. One patient developed ventricular tachyarrhythmia post-operatively which was treated with ablation and automatic internal cardiac defibrillator placement. The other patient suffered from a gastrointestinal hemorrhage that required bowel resection. Both of these patients were ultimately transferred to rehabilitation facilities, completely intact neurologically.

CONCLUSION. VA-ECMO may be useful as a bridge to LVAD implantation in select patients with refractory cardiogenic shock. As such, LVAD implantation should be considered in patients on VA-ECMO support who fail to recover cardiac function.