Objective
ECMO prior to VAD implantation as a “double-bridge” strategy to heart transplantation (HT) is often employed for the most acutely ill decompensated heart failure patients. This cohort of patients has worse outcomes than primary VAD. Early crossover from ECMO to VAD has shown to have better survival in double-bridged adults. This study aims to evaluate the outcomes of early vs late crossover in double-bridged pediatric patients using the ACTION registry.
Methods
All patients < 18 years of age in the ACTION 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-bridge. 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 double-bridged patients 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.
This ACTION study was published in JTCVS Open on January 31, 2026. Congratulations to the authors:
- Kishore R. Raja, MD
- Shezad Muhammad Farrukh, MD
- Benjamin Kroslowitz
- Matthew J. O’Connor, MD
- Lawrence Greiten, MD
- Jennifer Conway, MD
- Chesney Castleberry, MD
- Aamir Jeewa, MD
- Christina VanderPluym, MD
- Mark Bleiweis, MD
- John J. Parent, MD
- David Peng, MD
- Aryaz Sheybani, MD
- Gonzalo Wallis, MD
- Deepa Mokshagundam, MD
- David W. Bearl, MD
- Lindsay May, MD
- Arene Butto, MD
- Natalie Shwaish, MD
- Shahnawaz Amdani, MD
- Robroy MacIver, MD
- Ashish Ankola, MD
- Jennifer A. Su, MD
- Bethany Wisotzkey, MD
- Neha Bansal, MD
- Sabrina Law, MD
- Svetlana B. Shugh, MD
- Sarah Wilkens, MD
- Katerina Boucek, MD
- Scott Auerbach, MD
- Pranava Sinha, MD, MB
CITATION
Raja, Kishore R. et al. Double Bridge to Heart Transplantation: Outcomes of Early vs Delayed Extra Corporeal Membrane Oxygenator Crossover in Pediatric Population, JTCVS Open, 101608 (2026), DOI: 10.1016/j.xjon.2026.101608
