Double bridge to heart transplantation: Outcomes of early versus delayed extracorporeal membrane oxygenation crossover in pediatric population

Objective Extracorporeal membrane oxygenation (ECMO) before ventricular assist device (VAD) implantation as a “double-bridge” strategy to heart transplantation is often used for the most acutely ill patients with decompensated heart failure. This cohort of patients has worse outcomes than those with primary VAD. Early crossover from ECMO to VAD has shown to have better survival in adults who are double-bridged. This study aims to evaluate the outcomes of early versus late crossover in pediatric patients who were double-bridged using the Advanced Cardiac Therapies Improving Outcomes Network registry. Methods All patients <18 years of age in the Advanced Cardiac Therapies Improving Outcomes Network database who were double-bridged were identified. Patients were categorized into early or delayed crossover groups. Univariate and multivariate Cox regression analysis identified independent risk factors of outcomes. Kaplan-Meier and competing risk analyses assessed survival. Results Of 1360 patients, 334 (24%) underwent double-bridging. Median ECMO support was 6 days, leading to an early crossover group (≤6 days) of ECMO (n = 168) and a delayed crossover group (>6 days) of ECMO support (n = 166). Univariate analysis showed that patients who were double-bridged were considerably sicker than the primary VAD group. Multivariable analysis revealed that a diagnosis of dilated cardiomyopathy/myocarditis and bridge to candidacy device intent were independent predictors of outcome. Duration of ECMO support/timing of crossover (early vs late) was not independently associated with outcomes. Conclusions The timing of crossover from ECMO to VAD in pediatric patients subject to the double-bridge strategy does not affect outcomes. Focus on the patient selection and reversibility of risk factors rather than the duration of ECMO support may improve outcomes in this high-risk population.