Impact of Left Ventricular Unloading on Outcome of Heart Transplant Bridging With Extracorporeal Membrane Oxygenation Support in New Allocation Policy

Background The new heart allocation policy places veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO)‐supported heart transplant (HT) candidates at the highest priority status. Despite increasing evidence supporting left ventricular (LV) unloading during VA‐ECMO, the effect of LV unloading on transplant outcomes following bridging to HT with VA‐ECMO remains unknown. Methods and Results From October 18, 2018 to March 21, 2023, 624 patients on VA‐ECMO at the time of HT were identified in the United Network for Organ Sharing database and were divided into 2 groups: VA‐ECMO alone (N=384) versus VA‐ECMO with LV unloading (N=240). Subanalysis was performed in the LV unloading group: Impella (N=106) versus intra‐aortic balloon pump (N=134). Recipient age was younger in the VA‐ECMO alone group (48 versus 53 years, P=0.018), as was donor age (VA‐ECMO alone, 29 years versus LV unloading, 32 years, P=0.041). One‐year survival was comparable between groups (VA‐ECMO alone, 88.0±1.8% versus LV unloading, 90.4±2.1%; P=0.92). Multivariable Cox hazard model showed LV unloading was not associated with posttransplant mortality after HT (hazard ratio, 0.92; P=0.70). Different LV unloading methods had similar 1‐year survival (intra‐aortic balloon pump, 89.2±3.0% versus Impella, 92.4±2.8%; P=0.65). Posttransplant survival was comparable between different Impella versions (Impella 2.5, versus Impella CP, versus Impella 5.0, versus Impella 5.5). Conclusions Under the current allocation policy, LV unloading did not impact waitlist outcome and posttransplant survival in patients bridged to HT with VA‐ECMO, nor did mode of LV unloading. This highlights the importance of a tailored approach in HT candidates on VA‐ECMO, where routine LV unloading may not be universally necessary.