VA ‐ ECMO for cardiogenic shock in the contemporary era of heart transplantation: Which patients should be urgently transplanted?

With the impending United Network for Organ Sharing ( UNOS ) heart allocation policy giving VA ‐ ECMO supported heart transplant ( HT ) candidates highest priority status (Tier 1), identifying patients in cardiogenic shock ( CS ) with severe and irreversible heart failure ( HF ) appropriate for urgent HT is critically important. In a center where wait times currently preclude this approach, we retrospectively reviewed 119 patients (ages 18‐72) with CS from 1/2014 to 12/2016 who required VA ‐ ECMO for >24 hours. Underlying aetiologies included postcardiotomy shock (45), acute coronary syndromes (33), and acute‐on‐chronic HF (16). Eighty‐four percent of patients (100) had ≥1 contraindication to HT with 61.3% (73) having preexisting contraindications (eg, multiorgan dysfunction and substance abuse), and 68.1% (81) experienced preclusive complications (eg, renal failure, coagulopathy, and infection). Potential HT candidates were significantly more likely to survive to discharge (potential HT candidates 84.2% vs preexisting contraindications 43.8% vs contraindications developing on VA ‐ ECMO 33.3%, P  = 0.001). Among potential HT candidates, 11 (68.8%) were discharged without advanced therapies and 4 received durable left ventricular assist device (25.0%). Importantly, 1‐year survival was 100% for the 11 patients with follow‐up. Thus, further work is critical to define appropriate candidates for HT from VA ‐ ECMO while avoiding preemptive transplantation in those with otherwise favorable outcomes.