Short courses of VA ECMO can be lifesaving for patients experiencing acute cardiorespiratory failure; however, prolonged support may lead to increased risk of morbidity and mortality. The new UNOS Adult Heart Allocation Policy heightens the importance of timely transition to a durable mechanical circulatory support device.
Worldwide utilization of veno-arterial extracorporeal membrane oxygenation (VA ECMO) has risen sharply in recent years.1 Between 2006 and 2011, the use of VA ECMO rose as much as 411% in the United States.2
More recent data on SynCardia temporary Total Artificial Heart (TAH) recipients revealed a similar trend. According to data reported on SynCardia Implant Forms, only 4% of TAH patients were on ECMO support prior to TAH implantation in 2013. That number increased to 52% in 2017.3
While ECMO has proven to be an effective rescue therapy for patients experiencing severe cardiorespiratory failure, it is not a long-term solution.4 The patient’s survival ultimately depends on recovering their cardiac function, receiving a donor heart or being transitioned to a more durable form of circulatory support, with time being a critical factor.1,4
Several studies have reported increased rates of morbidity after approximately four days of VA ECMO support.4,5,6 Similarly, SynCardia data have shown that the survival rate at six months for TAH recipients who were not on ECMO prior to TAH implantation was 60%, versus only 47% for patients who were on ECMO prior to implantation.3
Timing of transition from ECMO is heightened under the new UNOS Adult Heart Allocation System. Under the previous UNOS Adult Heart Allocation Policy, VA ECMO patients were listed Status 1A indefinitely. However, the new policy stipulates that VA ECMO patients are listed Status 1 for only 7 days before dropping to Status 3 unless an exception is approved.
Given these new adult donor heart allocation criteria, it is critical to plan your transition strategy at the time you place the patient on ECMO and set a definitive time limit. If a donor heart does not become available or the patient’s condition does not stabilize by the specified time limit, implement your plan to transition the patient to a more durable form of mechanical circulatory support to optimize their outcome.
1 Baran DA. Extracorporeal Membrane Oxygenation (ECMO) and the Critical Cardiac Patient. Current Transplantation Reports. 2017;4(3):218-225. doi:10.1007/s40472-017-0158-5.
2 Sauer CM, Yuh DD, Bonde P. Extracorporeal Membrane Oxygenation Use Has Increased by 433% in Adults in the United States from 2006 to 2011. ASAIO Journal. 2015;61(1):31-36. doi:10.1097/mat.0000000000000160
3 SynCardia Implant and Explant forms. Not all Implant and Explant Forms are returned or have complete information.
4 Miles Smith, Alexander Vukomanovic, Daniel Brodie, Ravi Thiagarajan, Peter Rycus and Hergen Buscher Duration of veno-arterial extracorporeal life support (VA ECMO) and outcome: an analysis of the Extracorporeal Life Support Organization (ELSO) registry BioMed Central 2017
5 Gupta P, Robertson MJ, Beam B, Gossett JM, Schmitz ML, Carroll CL, et al. Relationship of ECMO duration with outcomes after pediatric cardiac surgery: a multi-institutional analysis. Minerva Anestesiol. 2015;81:619–27.
6 Merrill ED, Schoeneberg L, Sandesara P, Molitor-Kirsch E, O’Brien J, Dai H, et al. Outcomes after prolonged extracorporeal membrane oxygenation support in children with cardiac disease–Extracorporeal Life Support Organization registry study. J Thorac Cardiovasc Surg. 2014;148:582–8.