Mechanical circulatory support as bridge therapy for heart transplant: case series report
Garzon‑Rodriguez et al. BMC Res Notes
Mechanical circulatory support as bridge therapy for heart transplant: case series report
Javier D. Garzon‑Rodriguez 3
Carlos Obando‑Lopez 2
Manuel Giraldo‑Grueso 0 1
Nestor Sandoval‑Reyes 2
Jaime Camacho 2
Juan P. Umaña 2
0 Vascular Function Research Laboratory, Fundación Cardioinfantil‐ Instituto de Cardiología , Calle 163 A número 13B‐60, 111831 Bogotá , Colombia
1 Vascular Function Research Labo‐ ratory, Fundación Cardioinfantil‐Instituto de Cardiología , Calle 163 A número 13B‐60, 111831 Bogotá , Colombia
2 Cardiac Surgery Department, Fundación Cardioinfantil‐ Instituto de Cardiología , Bogotá , Colombia
3 Universidad del Rosario, Fundacion Cardioinfantil‐Instituto de Cardiología , Bogotá , Colombia
Background: Mechanical circulatory support (MCS) represents an effective urgent therapy for patients with cardiac arrest or end‑ stage cardiac failure. However, its use in developing countries as a bridge therapy remains controversial due to costs and limited duration. This study presents five patients who underwent MSC as bridge therapy for heart transplantation in a developing country. Case presentation: We present five patients who underwent MCS as bridge therapy for heart transplant between 2010 and 2015 at Fundación Cardioinfantil‑ Instituto de Cardiología. Four were male, median age was 36 (23-50) years. One patient had an ischemic cardiomyopathy, one a lymphocytic myocarditis, two had electrical storms (recurrent ventricular tachycardia) and one an ischemic cardiomyopathy with an electrical storm. Extracorporeal life support (ECLS) was used in three patients, left ventricular assistance in one, and double ventricular assistance in one (Levitronix® Centrimag®). Median assistance time was 8 (2.5-13) days. Due to the inability of cardiopulmonary bypass weaning, two patients required ECLS after transplant. One patient died in the intensive care unit due to type I graft rejection. Endpoints assessed were 30‑ day mortality, duration of bridge therapy and complications related to MCS. Patients that died on ECLS, or were successfully weaned off ECLS were not included in this study. Conclusions: MCS is often the only option of support for critically ill patients waiting for a heart transplant and could be considered as a short‑ term bridge therapy.
Heart‑ assist devices; Extracorporeal membrane oxygenation; Heart transplantation; Myocardial ischemia
The increase of life expectancy and ischemic heart
disease within the years has created long heart transplant
waiting lists. According to the United Network for Organ
Sharing, more than 3000 hearts per year are needed to
meet the waiting list demand in the United States;
however, less than 2000 heart donors per year are reported
]. In Colombia the median waiting list time for a heart
transplant was 59 (1–606) days in 2014 [
]. The use of
extracorporeal life support (ECLS) and ventricular assist
devices as a bridge therapy for a heart transplant has
been described as a feasible alternative [
the cost of the therapy, the success rate and the limited
duration of ECLS remain as subjects of concern [
We present five cases of mechanical circulatory support
(MSC) as a bridge therapy for a heart transplant and the
From January of 2010 to December 2015, five patients
underwent ECLS or ventricular assist devices as bridge
therapy for heart transplantation at Fundación
Cardioinfantil-Instituto de Cardiología, Bogotá-Colombia.
Patients that died on ECLS, or were successfully weaned
off ECLS are not presented. The ventricular assist device
used was the Levinotrix® CentriMag® (levitronix LLC;
The indications for MCS were: Ischemic
cardiomyopathy, lymphocytic myocarditis, and an electrical storm
(recurrent ventricular tachycardia). The interagency
registry for mechanically assisted circulatory support
(INTERMACS) was assessed in all patients. The primary
endpoints were 30-day mortality, duration of bridge
therapy and complications related to MCS.
Four patients were male. All patients were New York
heart association class IV. The median left ventricular
ejection fraction was 19% (15–20). One patient had an
ischemic cardiomyopathy, one a lymphocytic
myocarditis, two had electrical storms and one an ischemic
cardiomyopathy with an electrical storm (Table 1).
Before MCS, three patients required inotropic
support; four patients had an intra-aortic balloon pump.
One patient had mechanical ventilatory support and
three had organ dysfunction (acute kidney failure). All
patients underwent catheter ablation therapy due to
rhythm abnormalities. Four patients were INTERMACS
1 and one INTERMACS 2. One patient presented
transit ischemic attack (right-side hemiparesia that disappear
within 1 h, without medical therapy) (Table 1).
During MCS, one patient required left ventricular
assistance, two ECLS, and one biventricular assistance. The
median time of MCS prior to heart transplantation was
8 (2.5–13) days. Two patients had vascular complications
during MCS, one developed leg ischemia; the other one
required a surgical exploration due to bleeding at the
insertion site of the femoral cannulae (Table 1).
After the heart transplant, four patients continued
with an intra-aortic balloon pump, and two required
ECLS due to the inability of cardiopulmonary bypass
weaning. Two patients developed a pericardial effusion;
both of them required a percutaneous drainage. One
patient developed a hemopericardium that was managed
through a sternotomy. One patient died in the intensive
care unit due to type 1 graft rejection and multiple organ
dysfunctions (Table 1).
Discussion and conclusions
MCS is a useful alternative for the management of
critically ill patients with cardiogenic shock, refractory
cardiac failure or potentially fatal arrhythmias [
Latin America, there are no publications describing the
use of ECLS and ventricular assist devices as a bridge
therapy for heart transplantation, and adult patients are
rarely bridged to transplantation due to difficulties in the
urgent medical evaluation. Therefore this study
contributes to an emerging field and could indicate ECLS and
ventricular assist devices are a feasible bridge for a heart
All the patients we described received MCS as a bridge
for transplant. Waiting time for organ availability was
short since the average duration of the bridge therapy
was 8 days. Some studies described the need for at least
3 weeks of ECLS before transplant [
]. However, poor
outcomes are reported with prolonged use of ECLS, the
frequency of bleeding, infection or embolism begins to
rise after the first 7 days [
]. In our series, all patients
were listed as high-urgency.
Recent studies have shown good results after a heart
transplant in patients with preoperative ECLS [
Pre-existing organ dysfunction elevated blood urea, and
liver function are significant predictors of death.
Therefore if the patient has multiple organ failures the bridge
therapy should not be considered [
The prognosis after heart transplant seems to be
superior in patients with INTERMACS 1, which underwent
ECLS at an early stage [
]. In our series, we showed that
all patients INTERMACS 1 accomplished hemodynamic
stabilization during ECLS therapy that enabled them to
achieve a successful heart transplant.
Patients in our series, were young (median age 36 years)
had a poor functional class, a low left ventricular
ejection fraction (median 19%) and biventricular failure with
pulmonary edema. Barth and colleagues [
] reported a
cohort of 8 patients with bridge therapy, the mean left
ventricular ejection fraction was 17.5%, the mean age was
49 years and they also had a poor functional class.
Ischemic cardiomyopathy is the most common
indication for a heart transplant [
]. In our series we found a
high frequency of electric storms, these patients received
a conservative inotropic management and underwent
ECLS due to the high risk of sudden death. Two patients
had vascular complications during MCS, one developed
leg ischemia; the other one required a surgical
exploration due to bleeding at the insertion site of the femoral
cannulae. In both patients, the cannulae was adjusted
and no motor deficits were observed.
In our series, we found a high incidence of bleeding
reoperations. Three patients developed cardiac
tamponade secondary to hemopericardium or pericardial
effusion, which was managed with pericardiocentesis or a
median sternotomy. This is higher than the previously
reported series, which describes 28% of bleeding
]. Ranjit and colleagues [
] reported a 4%
frequency of infectious complications, although our series
have only five patients, it is worth noting that the
freedom from infectious complication was 100%.
Only one patient died after heart transplant as a result
of a type 1 graft rejection which evolved to multisystemic
organ failure. This condition is associated with a high
mortality rate (almost 80%) despite optimal treatment, or
MCS is often the only option of support for critically
ill patients (refractory heart failure, cardiogenic shock
or electric storm) needing a heart transplant. We
suggest considering ECLS and ventricular assist devices as
a short-term bridge therapy, since the mechanic support
becomes a real alternative due to hemodynamic
stabilization and gives time to find a heart donor. However,
patients in ECLS have more complications, especially
with increasing duration of use.
ECLS: extracorporeal life support; INTERMACS: the interagency registry for
mechanically assisted circulatory support; MCS: mechanical circulatory
JU, JC, NS, CO, JG were the cardiac surgeons in charge of the patients and
made important intellectual contributions. MG made substantial contribu‑
tions to conception, design, and data acquisition. JG and MG structured the
article and were involved in drafting the manuscript and revising it critically
for important intellectual content. All authors read and approved the final
We will like to thank the anesthesia department and the research department
for the advisory and corrections for this manuscript.
The authors declare that they have no competing interests.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from
the corresponding author on reasonable request.
Consent for publication
Written informed consent was obtained from study participants for participation
in the study and for publication of this report. Consent and approval for publica‑
tion was also obtained from the “Comité de ética en investigación clínica”of
Fundación CardioinfantilI‑nstituto de Cardiología Bogotá‑ Colombia.
Ethics approval and consent to participate
All patients gave their permission to allow their information to be used in this
case report. The manuscript was approved by the institutional review board
“Comité de Ética en Investigación Clínica”.
No funding was obtained for this study.
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
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