Extracorporeal life support (ECLS) as bridging therapy in patients with cardiomyopathy and acute decompensation

Objectives: Newly diagnosed or acute exacerbation of chronic cardiomyopathy (CM) may quickly lead to decompensation and cardiogenic shock. Assist device implantation in these cases is associated with poor outcome and barely feasible under cardiopulmonary resuscitation (CPR). ECLS implantation achieves immediate cardiopulmonary stabilization and allows for end organ recovery. We report on the results of percutaneous ECLS implantation in patients with CM-related refractory cardiogenic shock after conventional therapy had failed.

Methods: We retrospectively analyzed 13 patients (2 (15%) female, mean age 47 ± 12 years) undergoing ECLS implantation from August 2012 until August 2013 for cardiogenic shock due to CM. 6 patients (46%) suffered from a dilative, 4 (31%) from various CMs. In 3 cases (23%) the pathology was unclear. 5 patients (39%) had been resuscitated and 2 (15%) were implanted under ongoing CPR. In 3 cases (23%) the patient's condition was too critical for transport and ECLS implantation was performed in the referring hospital by our team. After stabilization under ECLS, the patients were transported to our center. 3 patients (23%) were conscious during ECLS implantation and therapy. In 1, balloon atrial septostomy for left ventricle unloading was done.

Results: Overall 30-day survival was 54% (7 patients). Surviving patients were significantly younger (41 ± 8 vs. 54 ± 11 years, p = 0.033). 3 patients (23%) died during ECLS support, 2 due to multi-organ failure (MOF), 1 of intracranial bleeding (previous CPR and systemic lysis). 1 (8%) received heart transplant during ECLS support, 2 (15%) a biventricular assist device (B-VAD, Berlin Heart EXCOR®) of whom 1 died due to MOF. 7 patients (54%) were weaned successfully. 2 of these died within 30 days, 1 of MOF, 1 refusing VAD implantation due to heart failure.

Conclusion: ECLS may serve as a bridging therapy to VAD implantation (bridge-to-bridge/-destination) or heart transplant (bridge-to-transplant) in critically ill patients with CM. Even weaning is possible (bridge-to-recovery). Benefits of initial ECLS therapy before VAD implantation are end organ recovery allowing VAD implantation to happen under stable conditions and after neurological evaluation. VAD implantation might be performed on ECLS without switching to a conventional cardiopulmonary bypass to reduce its side effects. In case a univentricular VAD is possible, the ECLS system may remain in-situ for initial right ventricular or pulmonary support.