Life Impact of Venoarterial Extracorporeal Membrane Oxygenation Due to Primary Graft Dysfunction in Patients after Orthotopic Heart Transplantation

Background: 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 VA-ECMO survivors after HTX is comparable to non-ECMO patients. However, impact on quality of life is unknown. This study investigated days alive and out of hospital (DAOH) as patient-centered outcome in HTX patients at 1 year after surgery.

Method: This retrospective single-center cohort study included patients who underwent HTX at the University Hospital Duesseldorf, Germany, from 2010 to 2020. Main exposure was VA-ECMO due to PGD (= initiation within the first 24 hours after surgery according to consensus conference on PGD). VA-ECMO and non-VA-ECMO patients were compared regarding the primary endpoint DAOH at 1 year after HTX. DAOH were calculated by individually summing up the days of all hospital stays per patient and subtracting them from 365 days. Subgroup analysis for VA-ECMO survivors was performed.

Results: A total of 144 patients were included in the analysis. Overall mortality of the whole cohort was 20.8%. One-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 [aHR]: 0.32, 95% CI: 0.15–0.74; p = 0.002). Mortality did not differ significantly between VA-ECMO survivors and non-ECMO patients (non-ECMO 14.3% [14/98] vs. VA-ECMO survivors 18.9% [7/37], aHR: 0.72, 95% CI: 0.27–1.90; p = 0.48). Overall median DAOH of the whole cohort were 293 (interquartile range: 224–321). DAOH were significantly higher in non-ECMO patients compared with VA-ECMO patients and VA-ECMO survivors (non-ECMO vs. VA-ECMO: median 310 [277–327] days vs. 243 [0–288] days; p ≤ 0.0001; non-ECMO versus VA-ECMO survivors: 310 [277–327] days vs. 253 (208–299) days; p ≤ 0.0001). Multivariable quantile regression revealed that besides VA-ECMO, neurological complications and postoperative renal replacement therapy were associated with reduced DAOH. Especially in patients of lower quantiles and poor DAOH, these variables showed significant impact.

Conclusion: Despite similar survival rates, VA-ECMO due to PGD after HTX has a relevant life impact as these patients spend significantly more time in hospital during the first year after surgery. Thus, DAOH may relevantly contribute to a more comprehensive assessment of outcome in this cohort.

Publication History

Article published online:
03 February 2022