I”IABP”ntentions and E“ECMO”xpectations of New Heart Transplant Donor Organ Allocation Policy

To the Editor: We appreciate Lebreton et al's1 response to our editorial on heart transplant organ allocation policy and its "Unintended" consequences on transplant listing practices in general context of direct transplant from extracorporeal membrane oxygenation (ECMO) bridging. Recent reports, including ours, have suggested poor posttransplant outcomes following the new policy and a very recent report including more patients has suggested continued poor outcomes in unadjusted cohort of patients but no difference in outcomes before and after policy change when adjusted for several risk factors.2–4 We recognize the fact that selected patients bridged to transplant directly from ECMO could have favorable outcomes, especially when they are isolated cardiac failure patients with no generalized comorbidities or end-organ dysfunction associated with the low output cardiac failure. However, historically the United Network for Organ Sharing data suggests that ECMO use at the time of transplant has been associated with decreased posttransplant survival.5 The authors have published their good outcomes in very selected patients bridged to transplant with ECMO.6 However, in our experience, very few patients urgently supported with ECMO for cardiogenic shock have limited comorbidities, no end-organ damage, and isolated cardiac failure. We do not necessarily disagree with their argument on how to select ECMO patients for transplant, but current United Network for Organ Sharing priority criteria do not distinguish between transplantable and nontransplantable ECMO patients. On the contrary, more ECMO patients could be better stabilized using a durable left ventricular assist device for a longer period and may have better outcomes on waiting list and posttransplant. We agree with the authors that there is likely some practice changing behavior whenever there is a policy change, but the overwhelming increase in ECMO, intraaortic balloon pump, and Impella use following the current new policy and the simultaneous decline in durable left ventricular assist device use is alarming and has an unknown effect for patients on the waiting list.