Role of advanced heart failure and transplant teams in extracorporeal membrane oxygenation management

Abstract

This article comments on the research by Zhang et al on the role of advanced heart failure and transplant teams in extracorporeal membrane oxygenation (ECMO) management. The study by Zhang et al indicates that direct advanced heart failure and transplant involvement improves survival in ECMO patients, especially those on veno-arterial ECMO. However, the optimal approach varies due to multiple factors. This article discusses the clinical implications, research design limitations, and future directions to enhance ECMO care.

Key Words: Advanced heart failure and transplant team; Extracorporeal membrane oxygenation; Veno-arterial extracorporeal membrane oxygenation; Veno-venous extracorporeal membrane oxygenation; Multidisciplinary team collaboration

Core Tip: The study by Zhang et al suggests that direct involvement of advanced heart failure and transplant teams in extracorporeal membrane oxygenation (ECMO) management improves survival rates, particularly among patients on veno-arterial ECMO. However, the optimal approach can vary based on specific context and patient population. The article highlights the need for multidisciplinary collaboration, standardized protocols, and future research to enhance ECMO care outcomes.

TO THE EDITOR

Extracorporeal membrane oxygenation (ECMO) has become a crucial life-saving intervention for patients with severe cardiac and pulmonary failure refractory to conventional treatments[1]. Nevertheless, it is associated with high morbidity and mortality, and optimizing patient outcomes remains a challenge. The management of ECMO patients typically requires a multidisciplinary team, and the role of advanced heart failure and transplant (AHFTC) teams within this framework has been a subject of debate.

AHFTC teams, which are crucial in treating patients with refractory cardiogenic shock, provide specialized care for patients who are not able to find relief from typical heart failure treatments[2]. Their expertise in hemodynamic management and advanced cardiac therapies makes them suitable for leading and directly participating in ECMO patient care. However, the optimal way for AHFTC teams to be involved in ECMO management is controversial. Some studies suggest that direct AHFTC physician involvement can improve outcomes, while others find no significant difference or even potential disadvantages[3,4]. This discrepancy may stem from variability in team expertise, institutional protocols, or patient selection criteria. Potential risks of AHFTC-led models such as delayed decision-making in hierarchical structures or over-reliance on specialty input must also be considered, particularly in time-sensitive scenarios.

The study by Zhang et al[5] “Comparison of a direct vs consultative advanced heart failure role in the outcomes of extracorporeal membrane oxygenation patients”, published in the World Journal of Transplantation, compared ECMO outcomes between intensivist led teams and those with direct AHFTC physician involvement. The results showed that patients had a significantly higher 30-day post-discharge survival rate when AHFTC physicians played a direct role, particularly for veno-arterial (VA) ECMO patients. This finding highlights the potential benefits of direct AHFTC involvement in ECMO management. The authors emphasize that success in ECMO care hinges on collaborative frameworks rather than hierarchical leadership.

However, other studies have different results. A previous study examined the impact of a heart failure team providing input on decision-making for VA ECMO outcomes and found no difference in outcomes with that team’s involvement[3]. Tozzi et al[6] emphasized the importance of a multidisciplinary heart failure team in managing mechanical circulatory support, including ECMO, in a low-volume institution. They found that a structured heart team approach led to improved outcomes, highlighting the significance of coordinated care rather than solely focusing on the volume of procedures performed. These studies collectively underscore that the impact of AHFTC team involvement may depend on factors such as the specific context, patient population, and team member expertise, necessitating standardized protocols to harmonize multidisciplinary collaboration.

THE ROLE OF AHFTC TEAM IN CARDIOGENIC SHOCK PATIENTS

Zhang et al’s study indicates that when AHFTC teams lead the management of VA ECMO patients, 30-day post-hospital discharge survival improves significantly compared to a consultative approach[5]. This finding emphasizes the need for early AHFTC team involvement, not only in patient selection for ECMO but also in the weaning process and bridging patients to advanced therapies like left ventricular assist device implantation or transplantation[5]. Such an approach naturally supports the development of multidisciplinary collaboration models where the expertise of the AHFTC team complements that of intensivists in achieving hemodynamic stabilization.

To mitigate selection bias and enhance decision-making, objective risk stratification tools such as the respiratory ECMO survival prediction and survival after VA-ECMO scores should be systematically implemented, as emphasized by Dalia et al[7]. Structured ECMO competency frameworks integrated into AHFTC and critical care fellowship training programs are crucial for standardizing expertise and improving team performance. Simulation based ECMO modules, when incorporated into these curricula, can bridge skill gaps, particularly in low-volume institutions. This not only equips physicians with the necessary skills but also enables them to utilize objective risk stratification tools more effectively, ultimately optimizing healthcare delivery. Dalia et al[7] and Crespo-Leiro et al[8] collectively highlight that multidisciplinary team training and protocolized collaboration directly enhance clinical decision quality and patient outcomes. Additionally, structured ECMO training frameworks must account for institutional resource disparities. For example, low-volume centers may benefit from simulation-based programs and partnerships with high-volume ECMO hubs to standardize skills. Furthermore, cost-effectiveness analyses should guide investments in specialized teams, ensuring that financial burdens do not outweigh clinical benefits.

Optimizing anticoagulation protocols is also crucial. High stroke rates have been observed in consultative cohorts, and adjusting the targets for activated clotting time or anti-Xa levels may reduce such complications. Establishing a robust post discharge follow up system for heart failure patients is essential to maintain the survival benefits achieved during the acute care phase.

FUTURE DIRECTIONS

While Zhang et al’s findings highlight the potential survival benefits of AHFTC-led management in VA-ECMO patients, methodological constraints - including the single-center, retrospective design and small cohort size - limit the generalizability of their conclusions[5]. Risks of temporal confounding and baseline imbalances (e.g., higher vasopressor use and renal replacement therapy in consultative groups) suggest unmeasured differences in illness severity. While advocating for AHFTC-led models, it is critical to acknowledge the challenges of implementing such frameworks in non-tertiary or resource-limited settings. Smaller institutions may face barriers such as staffing shortages, limited ECMO case volumes, and financial constraints. Future studies should evaluate cost-effectiveness metrics (e.g., cost per quality-adjusted life year) and propose scalable adaptations, such as regional ECMO referral networks or telemedicine-supported AHFTC collaboration, to ensure equitable access. To address these limitations, large-scale, multicenter prospective studies employing propensity score matching are imperative to validate the survival advantage of AHFTC-driven models. Concurrently, research should explore ECMO’s physiological impacts on renal and hepatic function to refine personalized decision-support tools, while cost-effectiveness analyses of specialized multidisciplinary ECMO teams could optimize resource allocation in high-risk clinical settings[9]. The research also suggests that variability in ECMO experience among intensivists could influence outcomes, though the exact mechanisms underlying this variability remain unclear.

To bridge expertise gaps, we advocate for innovative subspecialty training pathways within AHFTC curricula, leveraging elective time to equip critical care cardiologists with advanced ECMO management skills[10]. Future studies should compare outcomes between AHFTC teams and intensivists with equivalent ECMO-specific training to reduce disparities in expertise. Furthermore, comparative analyses of an “AHFTC-led with intensivist-collaborative” model vs an “intensivist-led with AHFTC consultative” approach could refine role delineation-for instance, designating AHFTC for transplant evaluations while intensivists oversee hemodynamic stabilization. Longitudinal tracking of the patient journey from admission to discharge would enable quantification of AHFTC intervention patterns, such as the timing of transplant eligibility assessments or anticoagulation strategy adjustments.

Clinically, establishing multidisciplinary AHFTC-led teams for VA-ECMO patients, supported by standardized protocols and an ECMO registry for systematic auditing of clinical decisions and outcomes, may identify actionable improvement targets. Incorporating ECMO competency frameworks into continuing education programs for both AHFTC and critical care teams would ensure consistent skill levels. Notably, the study observed no statistically significant survival benefit in veno-venous ECMO patients managed by AHFTC teams, necessitating larger cohort studies to explore potential subgroup effects (e.g., etiology-specific responses). Additionally, ethical consensus building and patient preference assessments are warranted to clarify whether AHFTC should assume full oversight of ECMO management or adopt shared decision-making models with intensivists.

In summary, success in ECMO care hinges on systemic collaboration and protocol adherence rather than specialty dominance. A structured research sequence - spanning mechanism exploration, multicenter validation, and implementation optimization - is essential to translate AHFTC team strengths into scalable clinical pathways. Concurrently, strategic resource allocation and sustainable interprofessional collaboration frameworks will be pivotal to enhancing ECMO care quality comprehensively. By harmonizing rigorous research, structured training, and ethical practice, clinicians and researchers can achieve comprehensive, patient-centric advancements in ECMO management.