Life impact of VA-ECMO due to primary graft dysfunction in patients after orthotopic heart transplantation

René M'Pembele; Sebastian Roth; Alexandra Stroda; Giovanna Lurati Buse; Stephan U Sixt; Ralf Westenfeld; Amin Polzin; Philipp Rellecke; Igor Tudorache; Markus W Hollmann; Hug Aubin; Payam Akhyari; Artur Lichtenberg; Ragnar Huhn; Udo Boeken

doi:10.1002/ehf2.13686

Life impact of VA-ECMO due to primary graft dysfunction in patients after orthotopic heart transplantation

ESC Heart Fail. 2022 Feb;9(1):695-703. doi: 10.1002/ehf2.13686. Epub 2021 Nov 4.

Authors

Affiliations

¹ Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
² Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
³ Department of Cardiac Surgery, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
⁴ Department of Anesthesiology, Amsterdam University Medical Center (AUMC), Location AMC, Amsterdam, The Netherlands.

Abstract

Aims: Primary graft dysfunction (PGD) is a feared complication after heart transplantation (HTX). HTX patients frequently receive veno-arterial extracorporeal membrane oxygenation (VA-ECMO) until graft recovery. Long-term mortality of patients weaned from VA-ECMO after HTX is comparable with non-ECMO patients. However, impact on quality of life is unknown. This study investigated days alive and out of hospital (DAOH) as patient-centred outcome in HTX patients at 1 year after surgery.

Methods and results: This retrospective single-centre cohort study included patients who underwent HTX at the University Hospital Düsseldorf, Germany, from 2010 to 2020. Main exposure was VA-ECMO due to PGD. VA-ECMO and non-VA-ECMO patients were compared regarding the primary endpoint DAOH at 1 year after HTX. Subgroup analysis for patients weaned from VA-ECMO was performed. In total, 144 patients were included into analysis; 1 year mortality was significantly lower in non-ECMO patients [non-ECMO 14.3% (14/98) vs. VA-ECMO 34.8% (16/46), adjusted hazard ratio: 0.32, 95% confidence interval: 0.15-0.74; P = 0.002]. Mortality did not differ significantly between patients weaned from VA-ECMO and non-ECMO patients [non-ECMO 14.3% (14/98) vs. VA-ECMO (weaned) 18.9% (7/37), adjusted hazard ratio: 0.72, 95% confidence interval: 0.27-1.90; P = 0.48]. DAOH were significantly higher in non-ECMO patients compared with VA-ECMO patients and patients weaned from VA-ECMO [non-ECMO vs. VA-ECMO: median 310 (inter-quartile range 277-327) days vs. 243 (0-288) days; P < 0.0001; non-ECMO vs. VA-ECMO (weaned): 310 (277-327) days vs. 253 (208-299) days; P < 0.0001]. These results were still significant after multivariable adjustment with forced entry of predefined covariables.

Conclusions: Despite similar survival rates, VA-ECMO due to PGD has a relevant life impact as defined by DAOH in the first year after HTX. As a more patient-centred endpoint, DAOH may contribute to a more comprehensive assessment of outcome in HTX patients.

Keywords: Cardiac surgery; Days alive and out of hospital; ECLS; Patient-centred outcomes; Quality of life; VA-ECMO.

MeSH terms

Cohort Studies
Extracorporeal Membrane Oxygenation* / methods
Heart Transplantation* / adverse effects
Humans
Primary Graft Dysfunction* / epidemiology
Primary Graft Dysfunction* / etiology
Quality of Life
Retrospective Studies