1
|
Topkara VK, Sayer GT, Clerkin KJ, Wever-Pinzon O, Takeda K, Takayama H, Selzman CH, Naka Y, Burkhoff D, Stehlik J, Farr MA, Fang JC, Uriel N, Drakos SG. Recovery With Temporary Mechanical Circulatory Support While Waitlisted for Heart Transplantation. J Am Coll Cardiol 2022; 79:900-913. [PMID: 35241224 PMCID: PMC8928585 DOI: 10.1016/j.jacc.2021.12.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The 2018 U.S. heart allocation system offers an accelerated pathway for heart transplantation to the most urgent patients. OBJECTIVES This study sought to determine whether the new allocation system resulted in lower likelihood of candidate recovery. METHODS Adult patients waitlisted for heart transplantation with temporary mechanical circulatory support at the time of initial listing between 2010 and 2020 in the United Network for Organ Sharing registry were included. Competing events of heart transplantation, waitlist death or delisting for deteriorating condition, and delisting for improved condition (candidate recovery) were analyzed in the new vs old heart allocation system. RESULTS A total of 688 patients were waitlisted with venoarterial extracorporeal membrane oxygenation or a surgical nondischargeable biventricular assist device (status 1 or old 1A). Overall, 2,237 patients were waitlisted with an intra-aortic balloon pump, a percutaneous left ventricular assist device (LVAD), or a surgical nondischargeable LVAD (status 2 or old 1A). Patients waitlisted with venoarterial extracorporeal membrane oxygenation or a nondischargeable biventricular assist device had significantly shorter median waitlist times (5 vs 31 days), higher incidence for cardiac transplantation (81.5% vs 43.0%), and lower incidence of candidate recovery (1.5% vs 7.9%) in the new vs old heart allocation system (all P < 0.05). Patients waitlisted with an intra-aortic balloon pump or percutaneous or a nondischargeable LVAD also had significantly shorter median waitlist times (8 vs 35 days), higher incidence of transplantation (88.9% vs 64.9%), and lower incidence of candidate recovery (0.2% vs 1.6%) in the new vs old heart allocation system (all P < 0.05). CONCLUSIONS Current practice of the new allocation system may not offer select temporary mechanical circulatory support patients the opportunity and adequate time to recover to the point of waitlist removal. Further research will determine which patients would benefit from urgent transplantation vs recovery strategy.
Collapse
Affiliation(s)
- Veli K Topkara
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA.
| | - Gabriel T Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Kevin J Clerkin
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Daniel Burkhoff
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Maryjane A Farr
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - James C Fang
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| |
Collapse
|
2
|
Ibrahim M, Acker MA, Szeto W, Gutsche J, Williams M, Atluri P, Woods M, Richards T, Gardner TJ, McGarvey J, Epler M, Wald J, Rame E, Birati E, Bermudez C. Proposal for a trial of early left ventricular venting during venoarterial extracorporeal membrane oxygenation for cardiogenic shock. JTCVS OPEN 2021; 8:393-400. [PMID: 36004109 PMCID: PMC9390694 DOI: 10.1016/j.xjon.2021.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 07/26/2021] [Indexed: 11/07/2022]
Abstract
Objective Patients with profound cardiogenic shock may require venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for circulatory support most commonly via the femoral vessels. The rate of cardiac recovery in this population remains low, possibly because peripheral VA-ECMO increases ventricular afterload. Whether direct ventricular unloading in peripheral VA-ECMO enhances cardiac recovery is unknown, but is being more frequently utilized. A randomized trial is warranted to evaluate the clinical effectiveness of percutaneous left ventricle venting to enhance cardiac recovery in the setting of VA-ECMO. Methods We describe the rationale, design, and initial testing of a randomized controlled trial of VA-ECMO with and without percutaneous left ventricle venting using a percutaneous micro-axial ventricular assist device. Results This is an ongoing prospective randomized controlled trial in adult patients with primary cardiac failure presenting in cardiogenic shock requiring peripheral VA-ECMO, designed to test the safety and effectiveness of percutaneous left ventricle venting in improving the rate of cardiac recovery. Conclusions The results of this nonindustry-sponsored trial will provide critical information on whether left ventricle unloading in peripheral VA-ECMO is safe and effective.
Collapse
|
3
|
Schutz A, Ghanta R. Commentary: Futility in the age of modern mechanical circulatory support. JTCVS OPEN 2020; 3:112-113. [PMID: 36003879 PMCID: PMC9390189 DOI: 10.1016/j.xjon.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 05/29/2020] [Accepted: 06/02/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Alexander Schutz
- Divisions of General and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Tex
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Ravi Ghanta
- Divisions of General and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Tex
- Address for reprints: Ravi Ghanta, MD, One Baylor Plaza, MS 390, Houston, TX 77030.
| |
Collapse
|
5
|
Fried JA, Masoumi A, Takeda K, Brodie D. How I approach weaning from venoarterial ECMO. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:307. [PMID: 32513218 PMCID: PMC7278069 DOI: 10.1186/s13054-020-03010-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 05/20/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Justin A Fried
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital, 622 West 168th Street, PH Building, 4th Floor, Room 129, New York, NY, 10032, USA.
| | - Amirali Masoumi
- Department of Medicine, Division of Cardiology, Columbia University Medical Center/New York-Presbyterian Hospital, 622 West 168th Street, PH Building, 4th Floor, Room 129, New York, NY, 10032, USA
| | - Koji Takeda
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY, USA
| |
Collapse
|