Commentary: Bridge to bridge: No longer a bridge too far for successful cardiac transplant

Central MessageIn patients with cardiogenic shock biventricular failure supported on venoarterial ECMO, Total Artificial Heart implantation can be used as a successful bridge to transplant.See Article page 1138. In transplant. See Cardiogenic (CS) is condition characterized by impaired cardiac output and end-organ hypoperfusion that results in significant morbidity mortality. It remains the leading cause of death after acute myocardial infarction despite improvements CS management, mortality high, at 30% 50% contemporary registries.1Papolos A.I. Kenigsberg B.B. Berg D.D. Alviar C.L. Bohula E. Burke J.A. et al.Management outcomes ICUs versus without teams.J Am Coll Cardiol. 2021; 78: 1309-1317Crossref PubMed Scopus (46) Google Scholar Treatment strategies include improving performance administration vasoactive medications, but often these are insufficient mechanical circulatory support (MCS) required improve perfusion rest failing myocardium. The use extracorporeal membrane oxygenation (VA-ECMO) has increased recent times provide severe CS. provides hemodynamic patients, allowing removal carbon dioxide. Nevertheless, this only short-term solution because frequently develop complications when VA-ECMO, increasing each additional day support. aim VA-ECMO recovery, sufficient time underlying dysfunction improve. If does not occur, may transplantation (BTT), or alternatively another more durable MCS device, bridge-to-bridge (BTB) strategy, for either recovery suitable donor organ become available.2Brahmbhatt D.H. Daly A.L. Luk A.C. Fan Billia F. Liberation from oxygenation: review.Circ Fail. 14: e007679Crossref (5) their study, Noly colleagues3Noly P.-E. Moriguchi J. Shah K.B. Anyanwu Mahr C. Skipper al.A approach heart using total artificial heart.J Thorac Cardiovasc Surg. 2023; 165: 1138-1148.e1Abstract Full Text PDF (2) describe multicenter, observational, North American experience (TAH) (SynCardia Systems, Tucson, Ariz) device temporary BTT liberation VA-ECMO.3Noly study reports 54 who were sequential BTB comparing them 163 TAH alone BTT. Despite BTB, having higher acuity (all INTERMACS profile 1) before implantation, important clinical outcomes, including discharge hospital (32% vs 37%; P = .09), survival transplant (59% 65% group; .44), (87% 83%; .82) similar those alone. Median was 3.0 months. authors should congratulated demonstrating feasibility bridging TAH. Patients have fewer options support, ventricular assist (VAD) alternative longer-term compare 2 discussion, registry data sufficiently granular afford meaningful comparison—the International Society Lung Transplantation Registry Mechanically Assisted Circulatory Support analyses various configurations both VAD.4Ton V.K. Xie R. Hernandez-Montfort Meyns B. Nakatani T. Yanase M. al.Short- long-term adverse events device: an IMACS analysis.J Transplant. 2020; 39: 342-352Abstract (28) Another concern volume implantation. centers performed bulk procedures, other 4 implanting than 5 devices per year. There robust evidence suggesting very-low (implanting 10 VADs) poorer compared experienced centers.5Cowger Stulak J.M. P. Dardas T.F. Pagani F.D. Dunlay S.M. al.Impact center left implantation: analysis.JACC 2017; 5: 691-699Crossref (49) surgeries maintain competence too. Finally, it unclear if high-volume preferentially choice, even VAD right-sided option, which add further bias into patient selection across different locations. limitations associated observational studies, report significantly contributes understanding feasible immediately need wait available. challenge clinicians field choosing strategy best suited individual patients; yet overcome. A heartThe Journal Thoracic Cardiovascular SurgeryVol. 165Issue 3PreviewThis aims sequence (ECMO) followed (TAH-t). Full-Text