National Outcomes of Nonintubated Extracorporeal Membrane Oxygenation as a Bridge to Heart Transplantation.

Abstract

Nonintubated venoarterial extracorporeal membrane oxygenation (ECMO) has been described in patients with refractory cardiogenic shock, but there are limited data on outcomes of this technique as a bridge to heart transplantation. We investigated this practice in a national cohort. Adult heart recipients bridged with ECMO from October 18, 2018, to September 30, 2023, in the United Network for Organ Sharing database were categorized by use of ECMO alone (ECMO-only) and ECMO with mechanical ventilation (ECMO+VENT) at transplant. Between groups, we compared posttransplant stroke, acute rejection, need for dialysis, length of stay, and survival. Of 857 recipients bridged with ECMO, 198 (23.1%) were bridged with ECMO+VENT and 659 (76.9%) were bridged with ECMO-only. ECMO-only vs ECMO+VENT recipients less frequently required intra-aortic balloon pump (18.8% vs 30.3%), more frequently were supported with a temporary ventricular assist device (26.6% vs 19.2%, P = .04), and had better pretransplant functional status. ECMO-only vs ECMO+VENT recipients had a lower likelihood of posttransplant stroke (6.2% vs 10.7%; adjusted odds ratio, 0.55; 95% CI, 0.31-0.97; P = .04) or needing posttransplant dialysis (24.7% vs 35.5%; adjusted odds ratio, 0.59; 95% CI, 0.40-0.87; P = .007). ECMO-only vs ECMO-VENT recipients also had shorter median length of stay (22 vs 26 days, P < .001) and higher posttransplant survival at 90 days (95.1% vs 91.1%; adjusted hazard ratio [aHR], 0.53; 95% CI, 0.29-0.98; P = .04), 1 year (91.2% vs 85.7%; aHR, 0.60; 95% CI, 0.37-0.98; P = .04), and 3 years (86.0% vs 77.6%; aHR, 0.63; 95% CI, 0.40-0.97; P = .04). Nonintubated ECMO was associated with better peritransplant outcomes and better short- and long-term survival after transplant compared with ECMO with mechanical ventilation. We support extubating ECMO-bridged candidates before transplant when possible.