ECMO as a bridge to decision: Recovery, VAD, or heart transplantation?

Background Our 8-year experience with ECMO support as a bridge to decision was reviewed. Methods A cohort of 124 consecutive patients received ECMO for refractory cardiogenic shock in our institution. Twenty-six of these were out of hospital cardiac arrests and were excluded from this analysis. The median age was 43 years, in the range of 11 to 73 years. Results The median duration of ECMO support was 4.5 days. Mortality while supported by ECMO was 50% with a median support time of 2 days. Weaning from ECMO was achieved for 49 patients with the following outcomes: cardiac recovery (60%), heart transplantation (26%), and VAD implantation (14%). Median duration of support before weaning was 8 days. Hospital survival was 83%, 61.5% and 71% for cardiac recovery, heart transplantation and VAD implantation, respectively. ECMO weaning was significantly improved in all patients who had normalized their renal function, and when duration of support > 6 days (HR: 4.255 [1.255–14.493], p = 0.02 and HR: 2.164 [1.152–4.082], p = 0.02, respectively). A creatinine level > 14 mg/l the day of weaning was a significant predictor of death (HR: 5.807 [1.089–30.953]; p = 0.04). Median follow up was 2.4 years; one-year survival rate was 78%, 51% and 75% for cardiac recovery, heart transplantation and VAD implantation, respectively. Conclusion With at least 6 days of support, ECMO allowed a better patient selection for myocardial recovery, VAD implantation or heart transplantation. Whether VAD implantation or heart transplant in those patients is a better indication remains to be evaluated.