V-A ECMO as a Bridge to Heart Transplantation: Impact of Changes in Management on Failure to Rescue and Long-Term Outcomes

Background: In the last decades, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has been increasingly used as a bridge to heart transplantation (HTx). This study investigates temporal trends in V-A ECMO management for HTx and explores its impact on early and long-term outcomes, including the concept of Failure to Rescue (FTR) from major complications. Methods: A multicentre retrospective study was conducted on patients bridged to HTx using V-A ECMO from 2003 to 2024 across five cardiac surgery Units. The primary endpoints included the evolution of V-A ECMO management and differences in early and long-term mortality. FTR was assessed as an indicator of postoperative care. Results: A total of 137 patients were included and divided into two time-period groups: first decade (2003-2013, n = 43) and second decade (2014-2024, n = 94). Peripheral V-A ECMO implantation was more frequent in the second decade compared with the first decade (37.8% vs. 61.1%; p = 0.013), as well as the use of a limb reperfusion (12.2% vs. 60.4%; p = 0.001). Microaxial-flow pump adoption as left ventricle unloading significantly increased in the second decade (2.7% vs. 25.8%, p = 0.002). Early mortality was comparable between the two groups (30.2% vs. 25.5%, first vs. second decade; p = 0.611). No statistically significant temporal change was observed in FTR rates over time. Long-term survival was 50% and 56% at 8 years in the first and second decade, respectively (p = 0.66). Conclusions: Despite improvements in VA-ECMO patients management, which led to an increase in the number of HTx, the incidence of mortality and major complications after HTx remained unchanged after 20 years.