Durable Mechanical Circulatory Support versus Organ Transplantation: Past, Present, and Future

For more than 30 years, heart transplantation has been a successful therapy for patients with terminal heart failure. Mechanical circulatory support (MCS) was developed as a therapy for end-stage heart failure at a time when cardiac transplantation was not yet a useful treatment modality. With the more successful outcomes of cardiac transplantation in the 1980s, MCS was applied as a bridge to transplantation. Because of donor scarcity and limited long-term survival, heart transplantation has had a trivial impact on the epidemiology of heart failure. Surgical implementation of MCS, both for short- and long-term treatment, affords physicians an opportunity for dramatic expansion of a meaningful therapy for these otherwise mortally ill patients. This review explores the evolution of mechanical circulatory support and its potential for providing long-term therapy, which may address the limitations of cardiac transplantation

Left ventricle unloading strategies in ECMO: A single‐center experience

ECMO is a life-saving technology capable of restoring perfusion but is not without significant complications that limit its realizable therapeutic benefit. ECMO-induced hemodynamics increase cardiac afterload risking left ventricular distention and impaired cardiac recovery. To mitigate potentially harmful effects, multiple strategies to unload the left ventricle (LV) are used in clinical practice but data supporting the optimal approach is presently lacking. We reviewed outcomes of our ECMO population from September 2015 through January 2019 to determine if our LV unloading strategies were associated with patient outcomes. We compared reactive (Group 1, n=30) versus immediate (Group 2, n=33) LV unloading and then compared patients unloaded with an Impella CP (n=19) versus an intra-aortic balloon pump (IABP, n=16), analyzing survival and ECMO-related complications. Survival was similar between Groups 1 and 2 (33 vs 42%, p=0.426) with Group 2 experiencing more clinically-significant hemorrhage (40 vs. 67%, p=0.034). Survival and ECMO-related complications were similar between patients unloaded with an Impella versus an IABP. However, the Impella group exhibited a higher rate of survival (37%) than predicted by their median SAVE score (18%). Our findings correlate with recent large cohort studies and motivate further work to design clinical guidelines and future trial design